Accident

Investigation S
Form
Date of collision / accident:

Time:

Date and time of accident report:

Exact location of collision including junctions and post code:

First Name: Surname(s):

Title: Mr/Mrs/Miss/Ms Date of birth:

Private Address: Business Address:

Post code: Post code:

Telephone No. (Home): Work Telephone No.:

Telephone No. (Mobile): Work Email Address:
Email:

Weather (please tick): Visibility (please tick):

What was the level of visibility at the time of the incident?

Where did the incident take place? (please tick):

Public road Private road Car park Delivery yard

Was the driver travelling (please tick):

Straight ahead Ahead left Ahead right Reversing straight Reversing left Reversing right Vehicle was
stationary

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 Speed before impact? Speed at impact?

Collision with (please tick):

Another vehicle Person Fixed object Building

If there was impact with a fixed object or building, please give details of damage
to the fixed object:

If pedestrians were involved in the accident, please give details of their injuries:

Was the driver on (please tick): Time started work:

Outward journey Return journey
Annual business mileage:

Does the individual drive on business How long had the driver been driving
regularly? (please tick): before the incident?
Yes No

Any driver training provided to the Does the driver have any current points on
driver? (please tick): their licence? (please tick):
Yes No Yes No

If yes, please give details of If yes, please give details (how many,
training provided: conviction date, conviction code):

Has the driver had any period of disqualification? (please tick):

Yes No

Has the driver had any accidents in the Did the Police attend the scene of
past 5 years? (please tick): accident? (please tick):
Yes No Yes No

If yes, please give details (date, who If yes, please give badge number of Police
was to blame, etc?): officer attending:

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Details of
Make and Model:
our vehicle
(Vehicle 1) Vehicle Type:

Registration Mark:

Colour:

Vehicle class (please tick): Manual/Automatic? (please tick):

LGV LCV PCV Car Manual Automatic

Was the vehicle loaded? (please tick): Is the vehicle managed by the business
Yes No
or is it ‘grey fleet’ or on hire? (please
tick):
Grey Fleet Hire
Is the driver an employee of the If ‘grey fleet’ was the driver the registered
business? (please tick): keeper?
Yes No
Yes No N/A

Details of damage to our vehicle / property:

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Details of Other
Vehicles Mr/Mrs/Miss/Ms Name:
Involved Address:
(if known)
(Vehicle 2)
Telephone No.:

Vehicle Registration Mark: Make, Model and Colour:

Details of damage to the vehicle:

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 Details of Other
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Vehicles Mr/Mrs/Miss/Ms Name:
Involved
(if known) Address:

(Vehicle 3)
Telephone No.:

Vehicle Registration Mark: Make, Model and Colour:

Details of damage to the vehicle:

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Additional
Details of Injuries to our Driver and Third
details... Parties:

Details of passengers in
third party vehicle/vehicles
No. of passengers:

Name and
addresses of
passengers:

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 Please state fully what happened:
Please give a full description of the circumstances of the accident and ensure that you
include details that answer the following questions:
• Where was the other vehicle when you first saw it?
• Where did you hit the vehicle or object?
• Where did the vehicle hit you?
• How heavy was the traffic?
• What was the speed limit?
• Was there any prior altercation with the third party?
• Describe your day leading up to the accident in terms of work load and stress levels etc.
• Was there any issue that distracted you before the collision?
• Were you under pressure to get to your destination?
• Where was your destination?
• How long had you been driving?
• Who do you think was responsible for the collision?
• How could the collision have been prevented?
• How familiar are you with the vehicle you were driving?
• Were you aware of any vehicle defects?
• If your vehicle was parked, was it parked legally?

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Witnesses
Please give names, addresses and
(If any telephone numbers.
present)
State whether witnesses are independent
or passengers in one of the vehicles.

Witness 1: Witness 2:

Vehicle Accident Witness Statement

Name of Witness:

Please give details of the circumstances of the incident and keep the statement factual.
Please state:
• What happened
• Who was responsible for the accident and why
• Any mitigating factors
• Root cause of the accident

I give my consent to this statement being made available to persons who have a relevant and
related interest in the alleged offence. I declare that these details are true in every respect.

Signed: Print: Date:

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 Plan of Collision Area:
Please draw a sketch of the collision / accident showing positions of vehicles 1 and 2,
direction of travel, street names, road signs, crossings, bollards, etc. It would be helpful
if you could indicate NORTH.

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To Be
Was the accident preventable?
Completed
By Manager

Was our employee to blame for Why did the accident happen?
the accident?

What would the driver do What other steps are required to prevent
differently to prevent an accident this driver having another collision?
in the same circumstances?

I declare that the information above is true. I understand that any incorrect or false statement may result
in disciplinary action.
I give my consent to this statement being made available to persons who have a relevant and related
interest in the alleged offence. I understand that the statement will be kept confidential and not
disclosed to any person who has no interest in this accident investigation.

Signed: Print: Date:

Document / Action Required Included Not Included Comments

Accident report form

Sketch of accident

Driver witness statement

Photographs of incident scene

Supplementary photographs of vehicle

Vehicle damage report

Supplementary photographs of collision scene

Statements from witnesses and third party driver

Map of collision location from Google Maps

Drivers accident record

Estimate of repair costs

Insurance claim reserve details

Tachograph records for driver

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