Accident Report Form

Section 3 — Accident Details

Date of Accident *

Time of Accident *

Location of Accident (full address / road name) *

Postcode

Weather Conditions *

Road Conditions *

Lighting Conditions *

Were you the driver? *

Yes No

Approx. speed at impact (mph)

Describe what happened (be as detailed as possible) *

Section 4 — Third Party Details (if applicable)

Third Party Name

Third Party Phone

Third Party Vehicle Reg

Third Party Insurer

Third Party Address (if known)

Section 5 — Damage & Injuries

Description of damage to your vehicle *

Description of damage to third-party vehicle / property

Were there any injuries? *

No injuries Minor Serious

If yes, please describe

Were there witnesses? *

Yes No

Witness contact details

Section 6 — Police / Emergency Services

Did the police attend? *

Yes No

Police Incident / Reference No.

Did an ambulance attend? *

Yes No

Hospital name (if attended)

Legal Notice — Road Traffic Act 1988, s.154

Under Section 154 of the Road Traffic Act 1988, the driver of a motor vehicle must, when required by a police officer or any person having reasonable grounds, give their name and address, the name and address of the vehicle owner, and the registration number of the vehicle. Failure to do so within 24 hours at a police station is an offence. Additionally, under the terms of your insurance policy, you are required to notify your insurer of any accident, loss, or damage as soon as reasonably possible and in any event within 14 days. Providing false or misleading information in this report may constitute fraud under the Fraud Act 2006 and may render your insurance void.

Declaration

I declare that the information provided in this accident report form is true and accurate to the best of my knowledge. I understand that providing false or misleading information may result in my policy being voided and could constitute a criminal offence under the Fraud Act 2006. I authorise Cover Me and its underwriters to process this information for the purposes of assessing and handling my claim, in accordance with the Data Protection Act 2018 and UK GDPR.

I have read and agree to the declaration above. I confirm that all information provided is true and accurate.

Policyholder Signature (type full name)

Date

By submitting, this form will be sent directly to our claims team at claims@cover-me.insure

Download a fillable PDF version of this form to complete and email to claims@cover-me.insure

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