Road Traffic Free Assessment Form

Please provide as much information as possible.

Your details

Full Name

Address

Postcode

Email address

Phone Numbers

Home

Work

Mobile

Date of Accident

Time of Accident

Location of Accident

Please describe what happened

Who do you think is to blame, and why?

How could the accident have been avoided?

Names and addresses of any witnesses

Details of any comments made by you or others immediately after the accident

Details of the vehicle you were in including:

Drivers name and address
Vehicle make, model and registration
Insurers name, address and policy number

Details of the person responsible for the accident including:

Full name and address
Vehicle make, model and registration
Insurers name, address and policy number

Could you provide a sketch plan and photographs of the area if required?

Did you have a valid Driving Licence and insurance cover?

Were you wearing a seatbelt?

Were the Police involved?

What damage was caused to your vehicle, including recovery, storage and repair costs?

Full details of injuries received

Did you attend hospital or your GP?

Details of treatment received

Details of if or when recovered from injuries

Details of ongoing injuries and disabilities

Details of any pre-existing conditions

Details of financial losses directly related to the accident

Any other information you feel is relevant