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(242) 397-2100

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Motor Accident Report Form

Please answer every question. Do not leave blanks

Client's Full Name

Street Address

Occupation

Employer

Email

Home Phone

Cell Phone

Work Phone

National Insurance Number

Policy Number

Policy inception

Day

Month

Year

Policy expiry

Day

Month

Year

Vehicle Information

Year, make and model of vehicle

Serial Number (VIN)

Plate Number

Are you the registered owner?

Yes

No

If not, please provide name and contact for registered owner

Name of finance company, if vehicle has a loan

Driver or person in charge of vehicle

Full name

Street address w PO Box

Email

Date of birth

Occupation

Employer

Home Phone

Cell Phone

Work Phone

Driver's licence number

Year driver's licence obtained

Driver's licence expiry date

National Insurance Number

Does the driver:

Have any physical disabilities?

Yes

No

If YES, please describe

Have any driving convictions?

Yes

No

If YES, please provide dates and details

Has the driver had any accidents in the past 3 years?

Yes

No

If YES, please provide dates and details

Was the driver acting within the scope of his authority and with your knowledge and consent?

Yes

No

Use of vehicle

What was the vehicle being used for at the time of the occurence?

What goods were being carried?

Please provide full particulars of damage to vehicle

Witnesses

Names, addresses and phone contacts for any PASSENGERS who were witnesses

Names, addresses and phone contacts for any INDEPENDENT PERSONS who were witnesses

Was accident reported to police?

Yes

No

If YES, please provide name and number of officer

Injuries

Please provide the following FOR EACH PERSON injured in the occurence

PERSON 1: full name and address

Were they wearing a seatbelt?

Yes

No

Injuries sustained and vehicle they were travelling in

PERSON 2: full name and address

Were they wearing a seatbelt?

Yes

No

Injuries sustained and vehicle they were travelling in

Third parties

Party 1

Make and registration number of vehicle (or description of property)

Owner's name, address and telephone

Driver's name, address and telephone

Insurers

Party 2

Make and registration number of vehicle (or description of property)

Owner's name, address and telephone

Driver's name, address and telephone

Insurers

Party 3

Make and registration number of vehicle (or description of property)

Owner's name, address and telephone

Driver's name, address and telephone

Insurers

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