Page 39 - On Call folder

Motor vehicle accident report form

From Denise Hodgkiss To Karen Mann

Telephone no. 01473 242370 Date

Policyholder details
Policyholder: RT Infrastructure Solutions Ltd
Policy/Certificate number: RG/FLE/6869010
Policyholder’s address 91 Dales Road
Ipswich
Suffolk
IP14JR
Occupation: Railway Signalling / Engineering
Telephone number 01473 242330
Is the insured VAT registered? Yes Yes / No

Driver in charge (of vehicle immediately before incident)
Driver’s name:
Driver’s address:

Telephone number:
Email:
Date of birth: DD/MM/YYYY
Occupation
Length of driver’s employment?
Current licence number:
Date of first full licence:
If not the policyholder, did the driver have Yes / No
the policyholder’s permission to drive?
Has driver ever been involved in any
accident or loss during the past three Yes / No
years?
If Yes, enter details here:

Has driver ever been prosecuted or
incurred a fixed penalty for an Yes / No
endorsable offence in connection with a
motor vehicle?
If Yes, enter details here:

Insured vehicle
Make:
Model:
Registration number:
Name of hire purchase company or
finance house interested (if any):
Description of damage:

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