Accident report form

Personal details of vehicle owner

First Name

Family Name

Company Name

Address

Phone

Occupation

License Number

Registered for GST?

Yes No

ABN

Was someone else driving your vehicle at the time of the incident?

No Yes

If yes, please fill in driver details below, otherwise skip to next section

Name

Phone

Address

Relationship to owner

Your Vehicle

Make

Model

Registration

Is your vehicle repairable?

Yes Total loss Unsure

Is your vehicle insured?

Yes - Comprehensive Yes - Third party property No

Insurance company name

Have you made a claim?

Yes No

Who is your preferred repairer?

Details of pre-existing damage, if any

Will you be hiring another vehicle, or suffering any loss of income?

Yes No

What is your estimate of pre-accident value ($)?

Was the vehicle towed?

Yes No

Are there storage charges accruing?

Yes No

Where can the vehicle be inspected?

The Accident

Date of accident

Time of accident

Location (Road or Street)

Suburb / Town

Explain how the accident occurred

At the time of the accident, the speed of your vehicle (kmh)

At the time of the accident, the speed of the other vehicle (kmh)

Who in your opinion was responsible for the accident?

Upload diagram of your accident

Personal Details

Particularise below any items which were damaged or destroyed as a result of the collision (including baby seats/riding gear):

At Fault Party Details

It is most important that the details here are accurate - eg the full name or at least initials of the actual driver of the other vehicle.

Name

Address

Phone

License No.

Approximate age

Name and address of owner if not the same as driver

Make of vehicle

Model

Registration

Detail damage to the other vehicle

Was the vehicle towed?

Yes No

Is the vehicle insured?

Yes No

If yes, which company?

Claim number/policy number

Kenyon and Ahmet Lawyers do not act in personal injury claims.

Injuries

Were you or any other person in your vehicle injured?

Yes No

If so, would you like us to provide a referral to you to a specialist personal injury lawyer?

Yes No

Police

The Law compels a report to the police if anyone involved was injured, proper details not fully exchanged or property owner not present.

Was the collision reported to the police?

Yes No

If yes, details of police:

Has either driver been charged?

Yes No Unsure

Was a breathalyzer test carried out?

Yes No Unsure

If yes, result:

Witnesses & Passengers

The Law compels a report to the police if anyone involved was injured, proper details not fully exchanged or property owner not present.

Were there any passengers in your vehicle?

Yes No

Were there any independent witnesses to the collision

Yes No

If yes, the names and addresses of the witness/witnesses:

I authorise Kenyon & Ahmet Lawyers of 406 Victoria St, Richmond VIC 3121, to contact me and discuss my motor vehicle collision.

I Agree to

- Refer any contact from the other party/insurers to Kenyon & Ahmet Lawyers.
- Provide to my lawyers all reasonable assistance and co-operation in relation to these instructions.
- Notify Kenyon & Ahmet Lawyers of any change of address by me and confirm that should I fail to do so, they are entitled to consider themselves no longer bound by my instructions.

I acknowledge that Kenyon & Ahmet Lawyers are relying upon the information supplied by me as to the circumstances and particulars surrounding the collision.

I Agree

Personal details of vehicle owner

Your Vehicle

The Accident

Personal Details

At Fault Party Details

Injuries

Police

Witnesses & Passengers

Contact info