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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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