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Motor Incident Report
Use this form to record vehicle incidents, third party details, witnesses and police information.
Please complete as much information as possible. Missing details may delay the handling of the incident.
Employee / Driver Name
Department / Role
Vehicle Details
Vehicle Registration
Make / Model
Current Mileage
Third Party Details
Third Party Driver Name
Third Party Telephone
Third Party Email
Third Party Postcode
Third Party Home Address
Employer / Policyholder Name and Address if different
Third Party Insurance Company
Third Party Policy Number
Third Party Vehicle Registration
Third Party Vehicle Make / Model
Third Party Vehicle Colour
Number of Passengers
Passenger Names if Known
Injured Persons
Was anyone injured?
Select
No
Yes
Injured Person Details
Incident Details
Incident Date
Incident Time
Location
Road Condition
Weather Conditions
Do you accept responsibility?
Select
Yes
No
Unsure
Estimated speed of insured vehicle
Estimated speed of third party vehicle
Lights displayed on insured vehicle
Lights displayed on third party vehicle
Full Circumstances of the Incident
Witness / CCTV / Police Details
Independent Witnesses
Dashcam or CCTV Available?
Select
Yes
No
Unknown
Who should be contacted to obtain footage?
Were details taken by police?
Select
Yes
No
Police Incident Reference
Police Officer / Station Details
Submit Report
Photos cannot be uploaded through this version yet. Please email any photographs, dashcam files or supporting evidence separately after submitting.
Submit Motor Incident Report