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Rubin Lewis O'Brien Solicitors

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Road Traffic Accident Report Form

Home / Services for You / Personal Injury / Road Traffic Accident Report Form

Personal Injury

Accident at Work Report Form
Slipping and Tripping Report Form
Road Traffic Accident Report Form

Please fill out this report in as much detail as you can to support your claim.

Road Traffic Accident Form

Your Details

Name

First Last

Phone

Occupation

National Insurance number

Email

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Accident Circumstances

Date of accident

MM slash DD slash YYYY

Time of accident

Hours

:

Minutes

Accident location

What was the condition of the road?

Wet

Dry

Snowy

Icy

Greasy

How was visibility?

Sunny

Dark

Foggy

Dusk/Dawn

Raining

Please provide a description of how the accident happened:

In your opinion, who was to blame for the accident and why?

Were the Police called to the accident?

Details of Officer who attended

Injuries and Losses

What injuries did you sustain?

Did you attend hospital? If so, which hospital and on what dates?

Did you/have you attended your GP?

Are you still suffering from your injuries?

Have you been absent from work as a result of this accident? If so, have you incurred a loss of earnings?

Have you incurred any other losses as a result of this accident?

Vehicle Policy Excess

Prescription charges

Damage to clothing/other items

Travelling expenses

Car hire expenses

Please outline financial amount of these losses and any other expenses incurred.

Third Party Insurance and Vehicle Details

Please provide details of the other driver/vehicle involved in the accident

Name

First Last

Phone

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Their vehicle make/model:

Their vehicle registration

Name of their insurer

Policy number (if known)

Please provide any other information you feel is relevant.

Witnesses/Passengers

Please list any witnesses or passengers

Name

First Last

Witness or Passenger?

Witness

Passenger

Phone

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Name

First Last

Witness or Passenger?

Witness

Passenger

Phone

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Name

First Last

Witness or Passenger?

Witness

Passenger

Phone

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

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Rubin Lewis O’Brien is a trading name of Rubin Lewis O’Brien LLP, a limited liability partnership registered in England & Wales (registered number OC334029) authorised and regulated by The Solicitors Regulation Authority (SRA number 484893).

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