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Submit an accident claim
Please make sure that you complete ALL sections of the form correctlly  
VEHICLE DETAILS
Registration Number
Make
Model
Date of registration
Mileage
Has the Vehicle been Modified from manaufacturer's standard?
If YES, please give details
Do you own the vehicle?
If NO, please give details
Does the HP or leasing company have
an interest in the vehicle?
If YES, please give details
Registered owner of the vehicle
DETAILS OF ACCIDENT
Date
Time
Location
Who do you feel was at fault
for the accident?
Speed of vehicle prior to impact
Weather conditions
Brief accident description
Number of passengers in vehicle
Did anyone take photographs at accident location?
DRIVER DETAILS
Name
Address
Date of birth
Telephone number
Mobile number
Occupation
Date passed driving test for vehicle given
Motor claims in last three years
(if none state none)
Motoring convictions/pending convictions
in last three years (if none, state none)
USE OF THE VEHICLE
Please state the exact purpose for which the vehicle was being used at the time of the incident ('Private' is not sufficient)
DAMAGE TO YOUR VEHICLE
Vehicle damage
Description of damage
(Front of vehicle)
Description of damage
(Rear of vehicle)
Description of damage
(Driver / off side)
Description of damage
(Passenger / near side)
Vehicle status
If b) or c) state location address of vehicle
Image upload (1)
Image upload (2)
Image upload (3)
Image upload (4)
THIRD PARTY VEHICLE INVOLVED
Make / model / colour
Registration number
Driver's name & address
Telephone number
Mobile number
Owner's name & address (if different
from driver's name & address)
Insurance company name & address
Policy number
Brief description of damage
Number of passengers in other vehicle
WITNESSES
In Your Vehicle  
Name and address
Independent  
Name and address
Did police attend?
PC name / number, police station etc
Are you claiming injury?        (if yes please detail below)
Details of injuries
Did ambulance attend?
Are your passengers claiming injury?        (if yes please detail below)
Details of passengers inuries
Was anyone cautioned / breathalysed?        (if yes please detail below)
Details of caution / breathalyser
DRIVER'S STATEMENT
YOU MUST READ THE NOTES BELOW BEFORE COMPLETING THIS PAGE
(prepared in contemplation of litigation)
I (name)
of (address)
Telephone number (own)
Other contact number
Do make this statement following a road traffic accident on (date)
With a third party I now know as (name)
of (address)
THE FACTS  
In your own words, tell us exactly what happened including details of the cars involved, weather conditions, visibility etc.
Sketch of the accident location (please scan sketch and upload)
DRIVER'S STATEMENT - NOTES FOR POLICYHOLDERS

The civil justice system in the UK is aimed at making the resolution of disputes quicker, cheaper and simpler by shortening time limits available for investigation and promoting earlier settlements.

In order for insurers to deal with claim speedily and effectively they and the appointed solicitors will rely on information contained within the accident report form. The purpose of the statement required on the previous page is to record details about the circumstances of the accident.

The Statement should be hand-written by the driver of the vehicle after he has read and understood the following notes:

  1. The driver of the vehicle at the time of the accident should complete this Statement as soon after the accident as possible, while the incident is still clear in their mind.
  2. The driver should complete his/her full name and address and give both their own telephone number and the telephone number of a family member in the event that we need to make contact and are unable to do so.
  3. Make sure that the driver keeps the facts of the accident accurate and to the point. We want to establish what actually happened.
  4. The driver should indicate who he/she believes is responsible for the accident and why (e.g. “I hold the other driver wholly responsible for the accident as he pulled out in front of me / drove into the rear of my vehicle/did not signal his intentions/was going too fast…. etc. I am responsible as I was unable to stop before colliding with the rear of the vehicle in front.”).
  5. A sketch plan of the accident location will assist in showing the direction and point of impact of the vehicles, and will confirm the information on the report form
  6. The statement concludes with a ‘Statement of Truth’ i.e. a statement that the person signing the statement believes that the facts stated in it are true. If court proceedings are brought the solicitors appointed by your insurers will deal with those proceedings and will rely upon the information contained in this accident report form. The driver making the statement on the previous page of this accident report form must therefore understand that by signing the Statement of Truth, he is authorising the solicitor to sign on his behalf court documents which will contain the facts set out in the witness statement. This will therefore be treated as the driver’s own statement and his belief that the facts stated are true. If it should subsequently appear that the driver did not have an honest belief in the truth of those facts then the driver will be liable to face proceedings for contempt of court.
  7. The driver should sign and date this Statement.
PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING

(1) I/we authorise our insurance company and their appointed solicitor to deal with any claim on my/our behalf as they see fit. I/we undertake to provide whatever assistance I/we are able to give as may be required
(2) I/we believe that the above statements are true to the best of my/our knowledge anhd belief.
(3) I/we have read and understood the declarations above.
(4) I/we understand that you may ask for information from other insurers to check the answers I/we have provided.
Signature of policyholder (or authorised signatory)
Date
Enter Security Code   
 

Important Notice Insurers pass information to the Claims and Underwriting Exchange Register, run by Insurance Database Services Ltd (IDS Ltd) and the Motor Insurance Anti-Fraud and Theft Register, run by the Association of British Insurers (ABI). The aim is to help us to check information provided and also to prevent fraudulent claims. Under the conditions of your policy, you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. We will pass information relating to this incident to the registers.
 
Brocars PLC trading as Brocars Accident Management is a company authorised by the Ministry of Justice in respect of regulated claims management activities with Authorisation Number CRM21970
 
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