IMPORTANT NOTICE, No Liability is admitted by issue of this Form. either owner nor driver may admit fault or Liability for this Accident ‘Do not answer communications abaut this Accident Direet these to the Insurance Company for Action, MOTOR ACCIDENT REPORT FORM Insurers Claim No: Brokers Ref. No. All questions on this form must be answered, Repairs mustnot be authorised without prior authority of | the Insurance Company. instr Name See reg ee eee Address. _ Business(Oceupatio Pon Number. Name of hire purchase or finance company Vemiene Make & Model_ zz a Reg, No. of vehiel Reg, No.of taller Name and Address of Own (SE State the exact purpose for which the vehicle was being used atthe Hime ofthe accident COMMERCIAL Description of goods being carried _ as ‘YHIGLES [Name of owner of goods 7 “Wasa teller attached? Weight of load on () Vehi (6) Trailer). riven Name, Occupation, Date of binh__ Address “Tal. No, Is he employed by you?, How long has he been in your service? ‘Was he diving with your permission? How long has be been driving motor vehicles? ‘Was he in any way to blame forthe accident? Did he admit Kiaility? Has he had any previous accidents? 30, how many, and approximate date? {as he any conviction for any offence in connection with any motor vehicle or any charges pending? Ifs0, details including dates : Does he hold a full 0 provisional licence to drive this vehicle? - 1F fll, state date when driving west first passed Sumber oes he own a Motor Vehicle? iffso, give name and address oF lasuter Driver's Policy No ACCIDENT Dave Time. aum/p.m. Pace ‘Type of Road surface Visibility Wet or by? \What lights were showing on your Vehicle? What warning did your driver give? Estimate speed before accident ‘Weather conditions a Dia Police take particulars? Iso, give Constable's number and staion ‘To which Police Station was the accident reporced? es ee -Atach copy Note of Intended proseeusion ian. Cumin Tum Over —>Draw sketch (stating approximate measurements) showing position of vehicles and persons cancemed and the direction in which they were travelling. Also show (ype and position of wali signs, skid marks, pedestrain crossings and any other relevant information. STATEMENT BY DRIVER Signature of Driver TATEMENT BY OWNER ‘OR INSURED. DAMAGE TO INSURED, State briefly apparent damage VEMICLI (Ghall cases where your vehicle is damaged and you are entitled to claim under your policy, please send at once'to the Company an estimate for repairs). Repairer’s name and address _ Isthe vehicle still in use?_When and where can itbe inspected? OTHER [Name and address of owner | Reg.No.| Name of Insurer other property damaged VEIICLES: ae ee sat INVOLVED AND. PROPERTY DAMAGED Name and address of driver PERSONS ae Relationship Driver or Passenge ers INIURED Danreandiadit tothe Insured _| Reg No. of vehicle Apparent injuries INDEPEND ae = WITNESSES 7 Adi PASSENGERS. Nain ae Iyyour Addi VEWICLE TDECLARE that these particulars are true and correct and undertake to Forward {and unanswered) any correspondence relating to this accident. Date. Signature of Insured