Car Accidents

Forename ^*

Surname ^*

Email Address ^*

Home Telephone

Mobile Telephone

Best time to call?

Yes
No

A) How old is the claimant? (years)

B) Where you the: (1) Driver
(2) Passenger
(3) Cyclist
(4) Pedestrian

C) If you were the driver, passenger or cyclist, how did the accident happen? (1) Was your vehicle hit from behind?
(2) Did a vehicle turn right in front of you?
(3) Did another vehicle pull out from a side road?
(4) Did you collide with the vehicle in front of you?
(5) Did you turn right in front of someone?
(6) Did you pull out from a side road?

D) If you were a pedestrian, how did the accident happen? (1) Were you on a designated crossing?
(2) Were you running across the road?
(3) Were you on the pavement?

E) Had you been drinking? Yes
No

F) What was the date of your accident?

G) Do you have the name and address of the driver of the other vehicle? Yes
No

H) Do you have the registration number of the other vehicle? Yes
No

I) Did the Police attend the road accident? Yes
No

J) Did the other person admit liability? Yes
No

K) Were you exceeding the speed limit? Yes
No

L) Did anyone else witness the road traffic accident? Yes
No

M) When did you go to your GP/Hospital?: (1) Within 24 hours
(2) Within 1 week
(3) Longer than 1 week
(4) Not at all

N) Any Additional Information