ROAD TRAFFIC ACCIDENT QUESTIONNAIRE
Title:
MrMrsMissMsDr
Other (specifiy)
Your full name:
Address:
Telephone No.:
Home
Work
Mobile
Other contact No. (if any):
Fax
E-Mail
Date of Birth:
If under 18 name of parent or guardian and their address (if different from above):
National Insurance Number:
Employedself employed
Job Title:
Employers/business: name, address and telephone no:
MarriedSingle
Name and dates of birth of any dependent children:
Tax Code (if known)
Tax Office (if known)
If self-employed, name, address and telephone number of accountants:
Name of General Practitioner:
Address of General Practitioner:
DETAILS OF ACCIDENT
Please give a description here of how the accident occurred. Include details of the position of the vehicles before and after impact. If Possible, use the sketch plan to illustrate further.
Sketch plan:
Date of Accident:
Time of Accident:
You were a:
PedestrianVehicle driverPassenger
If a passenger which seat were you in?
If a passenger who was the driver?
If you were a passenger, were there other passengers and if so, who were they and where were they sitting?
If you were a passenger, had the driver been drinking alcohol?
YESNO
If yes, did you know that he had been doing so?
How much had the driver drunk?
Had you been drinking?
If so, how much, when and where?
Were you wearing a seat belt?
If not, why?
Please give details of the vehicle in which you were driving or travelling:
It was a
Motor cycleBicycleCarVanLorry
Other (specify)
Make:
Model:
Registration No.:
If you were driving, are you the owner of the vehicle?
If not who is the owner of the vehicle?
Location of Accident: (Please be as precise as you can, identifying the road, any shops or other landmarks to enable the accident scene to be located):
Weather conditions:
Road conditions (eg. dry, wet, icy):
Light conditions/visibility:
Speed limit:
Your speed:
Name(s) and address(es) of other driver(s) involved:
...
biurokrat