Accident Notification Form Accident Notification Sections 50(3) Local Government (Miscellaneous Provisions) Act 1976 If a licensed vehicle is damaged, and that damage affects the safety, performance and appearance of the licensed vehicle or the comfort or convenience of persons carried then the accident MUST be reported in writing within 72 hours of the accident. Driver details These are the details of the person driving the vehicle at the time of the accident. Badge number Name First name Last name Address Address Line 1 Address Line 2 City County Postcode Country Email Phone Next Page Proprieter These are the details of the vehicle owner i.e company, licence holder - if different from the driver Name First name Last name Company name Address Address Line 1 Address Line 2 City County Postcode Country Email Phone Previous PageNext Page Vehicle details Plate number Plate expiry date Vehicle registration Colour Make and model Current mileage Previous PageNext Page Details about the accident Date of accident Time (approximately) Hours Minutes Seconds AM/PM AM PM Location Description of the incident Weather condition at the time Please select Sunny Heatwave Icy Snow Drizzle Heavy Rain Thunderstorm Were photos taken at the scene YesNo Were details exchanged with the other party YesNo If you selected no to the above question, a reason why is required: Was the incident reported to the police? YesNo Incident number What was the outcome of the police attendance? Previous PageNext Page Vehicle damage details Was the vehicle recovered or driveable following the incident? RecoveredDriveable Provide details of the vehicles current location and any recovery/storage company. Mileage at the time of the accident Upload: Photo 1 - Front of vehicle Upload: Photo 2 - Passenger side Upload: Photo 3 - Driver side Upload: Photo 4 - Back of vehicle Upload: Photo of damage 1 Upload: Photo of damage 2 Upload: Accident sketch Refer to the webpage for document Previous PageNext Page Injury details Were you (or the driver if completed by anyone other than the driver) injured? YesNo If yes, describe injuries sustained and if ability to drive was affected Did you seek medical advice? YesNoNot applicable Did you take time off work? YesNo If yes, when did you return to work? Were any passengers present in the vehicle at the time of the incident? YesNo If yes, how many passengers? Location in which you were travelling to (if applicable) Did the passenger(s) appear to be or report any injuries? YesNoNot applicable Was an ambulance called to the scene? YesNoNot applicable Previous PageNext Page Other parties involved Did the accident involve another vehicle? YesNo If no advise what your accident involved i.e tree, fence, lamppost If yes complete the following questions about the other vehicle/driver: Vehicle registration Make and model Name First name Last name Phone Did the other driver, or their passenger(s), appear to be or report any injuries? YesNo Replacement vehicle Has provision been sought for a replacement vehicle? YesNo Replacement vehicle provider (including telephone) Replacement vehicle registration, make & model Licence number Commencement date Declaration I believe that the facts stated in this accident report form are true. I understand that proceedings for contempt of court may be brought against anyone who makes, or causes to be made, a false statement in a document verified by a statement of truth without an honest belief in its truth I understand Previous Page Submit