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Claim Number: Accident Report Form Please complete this form fully. It is a condition of your policy to report all incidents as soon as possible even if you do not intend to make a claim. Policyholder MORELLI GROUP LIMITED Policy Number Address 1 VIKING COURT, SHEPSHED ROAD, HATHERN, LOUGHBOROUGH, LE12 5LZ Email Address steve.shaw@morelli.co.uk Phone Number 07768-546337 MF1703964/31/05 Depot Code 01509-843782 Fax No. Occupation / Business Are you registered with HM Customs & Excise as taxable for vat? If partially exempt what % can you reclaim? % Driver or person last in charge if unattended Name Date of Birth Address Postcode Home Phone No. Email address Bus. Phone No. Fax No. Occupation (full and any part time) Agency Driver? Was the driver using the vehicle with the Policyholder’s permission? Yes Is the driver in the Policyholders permanent employ? If “No” please explain below Yes Type of driving licence held? (Circle) Full Licence No. Provisional Yes/No If “Yes” for how long? LGV Groups HGV PCV Expiry Date Date of passing UK driving test for the class of vehicle involved in this incident? Are proceedings pending against the driver as a result of this or any other incident or traffic offence? Yes/No If “Yes” give details Please give details of all previous motoring convictions and any medical condition or physical / mental disabilities Please give details of any accidents or losses in the last three years Has the driver been declined or refused Motor Insurance? Yes/No If “Yes” give details below Vehicle Make Model Registration No. Is the vehicle registration document (V5) registered in the name of the Policyholder? Are you the owner of the vehicle? Yes/No Are you the main user of the vehicle? Yes/No Yes/No Trailer No. If “No” please state the name of the main user below Please confirm the exact usage of the vehicle at the time of the incident Vehicle damage Please confirm full details of the damage sustained to the vehicle and the point of impact (attach estimate if obtained) Is the vehicle still in use (i.e. mobile and road-worthy)? Yes/No Estimated cost of repairs £ When and where can the vehicle be examined? (please provide a phone number if possible) Incident details Date of incident Time of incident Street Speed of vehicles Width of road Town Yours mph Conditions mph Weather/visibility What lights was your vehicle displaying? Did the police take details of the incident? County Others Speed limit Street lights on? mph Yes / No What lights was the other vehicle displaying Yes/ No Officers name Number Did you make a written statement? Yes/No If “Yes” please give details below Station Was anybody cautioned? Yes/No If “Yes” please give details Who do you blame for the incident and why? Please confirm exactly how the incident happened and confirm details of all property damage If necessary please also provide a sketch of the incident to include the width of the roads, type and position of all road signs & markings, direction of travel of all parties involved and the points of impact(s) Witnesses Please confirm the names, addresses and telephone numbers of all independent witnesses to the incident Please confirm the names, addresses and telephone numbers of all passengers in your vehicle Other parties involved. Please confirm the names, addresses and telephone numbers of all other parties involved (continue on the reverse of this report form if necessary) Name & Address Telephone number Make, model & colour of vehicle Registration number Damage / point of impact Number of occupants Location of vehicle Insurance Company Address & Policy Number Name & Address Telephone number Make, model & colour of vehicle Registration number Damage / point of impact Number of occupants Location of vehicle Insurance Company Address & Policy Number Injured parties Please confirm details of all persons injured together with the nature and extent of the injuries sustained (continue on the reverse of this report form if necessary) Name & Address Telephone number State whether driver or passenger, and in which vehicle, or if a pedestrian If a vehicle occupant were seat belts fitted? Apparent injuries Yes / No If “Yes” were they in use at the time of the incident? Taken to hospital? Which hospital attended? Detained? Yes / No Yes / No Yes / No Notice &DeclarationPlease read carefully Notice: Insurers pass information to the Motor Insurance Anti-Fraud and Theft Register, run by the Association of British Insurers (ABI). The aim is to help us to check information provided and also to prevent fraudulent claims. Under the conditions of your policy, you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. We will pass information relating to this incident to the register. Declaration: I/We hereby declare that the above information and statements are true to the best of my/our knowledge and belief. I/We understand that you may ask for information from other Insurers to check the answers I/We have provided. No other insurance is in force and I/We will render every assistance required by the Underwriters. Driver’s Signature Date Policyholder’s or Company Official’s Signature Date