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Green Motion Hire Details

Naam

Rental Banch

Rental agreement number (Enter to help speed up your claim process)

Email

Telephone number

Accident Details

Number of Vehicles Involved

Select the number of vehicles involved in the accident

Registration of vehicle 1

Name(s), address & contact numbers of driver

Names of all passengers

Was anyone injured? If yes, please enter names, and contact numbers

Vehicle insurance company

Insurance policy reference

Registration of vehicle 2

Name(s), address & contact numbers of driver

Names of all passengers

Was anyone injured? If yes, please enter names, and contact numbers

Vehicle insurance company

Insurance policy reference

Registration of vehicle 3

Name(s), address & contact numbers of driver

Names of all passengers

Was anyone injured? If yes, please enter names, and contact numbers

Vehicle insurance company

Insurance policy reference

Registration of vehicle 4

Name(s), address & contact numbers of driver

Names of all passengers

Was anyone injured? If yes, please enter names, and contact numbers

Vehicle insurance company

Insurance policy reference

Registration of vehicle 5

Name(s), address & contact numbers of driver

Names of all passengers

Was anyone injured? If yes, please enter names, and contact numbers

Vehicle insurance company

Insurance policy reference

Uploaded Photos

Please take photos of all vehicles involved in the accident and surrounding situation.

Were you driving the car at the time of the accident? If NO please provide details of driver.

Registration / licence plate

Is the Vehicle Drivable?

Description and area of damage

Number of Passengers in the Green Motion Hire Vehicle?

Date & time of accident

Exact location (road name, direction of travel etc)

Type of road. Motorway? Local road? Narrow? Wide?

Weather and visibility conditions

Approximate speed of Green Motion vehicle

Approximate speed of other vehicles involved

Did any emergency services attend? If YES give details

Police reference number

Is there any witnesses to this accident?

Witnesses Full Name

Witnesses Email Address

Witnesses Phone Number

Describe the point of impact & damage to other vehicle(s)

Describe how the accident occurred. Please provide as much detail as possible.

Accident Sketch Please complete a sketch showing the accident

Who do you feel is at fault for this accident and why?

Upload Photos

Please upload any other helpful photos, such as scene of accident, 3rd party driving licences and other relevant documentation.

Statement of Truth

I believe that the facts stated in this defendant’s version of events are true. I understand that proceedings for contempt of court may be brought against me if I make, or cause to made, a false statement in a document verified by a statement of truth without an honest belief in its truth.

Naam

Signature

Datum

Are you willing to attend court on this matter if required?