Motor Incident Reporting (Same Day or Next Day - Don't Delay)

Online Speed Report - Input Form

Please Note:

* Indicates mandatory field the date field format is: dd/mm/yyyy We have provided help text to assist you with the completion of this form Help text to assist you with completion of this form

  POLICYHOLDER

Policyholder:  * Please enter the full name of the policyholder as displayed on the policy documentation Contact Name: * The full name of the person within your business that we need to correspond with if there is a need to do so Policy Number: * Please provide your policy or certificate number which should contain either a) 2 letters, 7 numbers and a letter OR b) 1 letter, 6 numbers, 3 letters, 4 numbers and a letter Contact Number: * Preferably the telephone number that we should contact or the fax number Contact Email: * The email address of the person within your business that we need to correspond with if there is a need to do so Broker Email:  The email address of your insurance broker contact if there is a need to make your broker aware of the incident report Operating Co. Code (if applicable):  The divisional, operating company or cost centre code for your area of operation if we have an active operating co. table to store the claims records against Your Reference:  The reference number you would like us to quote on future correspondence if there is an agreement to correspond or contact you

  DRIVER OF POLICYHOLDER'S VEHICLE

Name: * Please state Full name  Date of Birth:  Please provide wherever possible for claim validation and claims experience analysis purposes(dd/mm/yyyy)  Age: * If the driver's date of birth is not available the driver's current age should be entered Address:  Please enter the drivers full address and postcode  Date Test passed (for vehicle driven): * The date that the driver passed the driving test for the class of vehicle involved in the incident OR the period of time that the driver has held a full driving licence to drive the vehicle(dd/mm/yyyy) Please provide full details of all previous and pending motoring convictions and any physical or mental infirmity  It is important for us to be made aware of the conviction(s) date(s) and penalties imposed together with details of any prescribed medication where any physical or mental infirmity has been declared

  POLICYHOLDER'S VEHICLE

Make: * Name of vehicle manufacturer Model:  Model and specification of the vehicle Registration Number: * Registration Mark of the vehicle involved in the incident Damage sustained in this incident: Please provide as much detail as possible of the damage sustained in this incident only and the point of impact if known Number of Passengers:  The number of all passengers travelling in your vehicle, excluding the driver 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Where is the vehicle now?  Please confirm the exact location of the vehicle and contact details. If you are covered for any damage sustained by the insured vehicle in this incident and you are claiming under your policy with us please confirm the cost of any recovery and/or storage charges and any continuing storage charge costs

  OTHER PARTY INVOLVED

Name & Address:  Please confirm the full names, addresses and postcodes of the other parties involved Telephone Numbers:  Please provide us with all contact numbers (home, work or mobile) provided by the other parties so that , if necessary, we may contact them regarding this incident and any claims arising. Make/Model/Colour of vehicle:  Please provide the full make, model, and the colour of the other vehicles involved in the incident Registration Number:  Registration mark of the vehicle that the other party or parties were driving   Number of Passengers:  The number of all passengers, excluding the driver, travelling in the other vehicle or vehicles involved in this incident 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Damage to vehicle / Point of Impact:  Please provide as much detail as possible of the damage sustained in this incident only and the point of impact if known Name & Address of Insurers:  Please provide the full name and address and policy or certificate number of the motor insurers of all other vehicles involved. If there was more than 1 other vehicle involved in the incident please identify the insurer of each of the other parties involved in the incident Policy Number:  Please provide the full motor policy or certificate number as shown on the Certificate of Motor Insurance shown to you or provided to you by the other parties involved in the incident   Information on mitigation of losses passed to other party? Providing the information will help the other party to understand their common law duty to mitigate their loss and how we can help if they are not to blame for the incident No Yes Scene of accident information form completed?  By the insured driver completing the form and passing the relevant part of the form to the other party you will be providing them with your details, a contact telephone number and important information on available services and the other parties duty to mitigate their loss NoYes Did the other party sign for receipt of information provided? The other parties should be asked to sign the part of the form that your driver retains to show that they have been provided with this important information No Yes

  PERSONAL INJURY

Please confirm the names of all injured parties  and the nature and extent of all injuries sustained in this incident: Please also indicate if they were travelling in your driver’s vehicle, in or on another vehicle involved in the incident or pedestrians. Please also advise if, to your knowledge, any of the injured parties were taken to hospital from the scene of the incident.

  INCIDENT DETAILS

Date of Incident: * Please state the date on which the incident occured(dd/mm/yyyy)? Time of Incident:  Please be as precise as possible AM/PM:  Morning or Afternoon? AM PM Location of Incident:  Please confirm the name of the road(s) (and nearest junction number if the incident occurred on a motorway or dual carriageway or other trunk road) Town / County / Country:  In which town ,county (or region) and country did the incident occur?

  CIRCUMSTANCES OF INCIDENT

Please describe what actually happened: * It will help us if you clearly explain the circumstances and provide details of all road signs or markings and details of the weather and road conditions prevailing

  IS THE INSURED DRIVER FULLY
  TO BLAME FOR THIS INCIDENT?

Yes / No:  IF your driver is considered fully responsible for the incident we may be able to help the other (innocent) party with their claim by providing our claims services and controlling the expense involved No Yes   If "No" why not? * We will only offer our claims handling services to the other party if there is no doubt that your driver was entirely to blame for the incident

  WITNESSES

Please provide the names, addresses and telephone numbers of all witnesses to the incident : (Please indicate if any of them are known to your driver) This information can be crucial when investigating and assessing liability for the incident and identifying negligence. Please therefore provide full details of all witnesses to the incident and indicate against each person whether or not they were independent (not known to either party)

  ADDITIONAL COMMENTS

Please provide any further comments on the incident that you would like to bring to our attention: Please tell us about anything else relevant to this incident that you feel we should be aware of. You can always tell us more as further information becomes available but we would like to know as much about the incident as possible – as early as possible

>> PLEASE EMAIL FAX OR COMPLETE THIS FORM ONLINE IMMEDIATELY >> IF YOU REPORT NEW INCIDENTS QUICKLY WE CAN MINIMISE THE COST OF CLAIMS

Notice & Declaration (please read carefully)

Notice: Insurers pass information to the Claims and Underwriting Exchange Register (CUE), run by Insurance Database Services Ltd (IDSL) and the Motor Insurance Anti-Fraud and Theft Register (MIAFTR), run by the Association of British Insurers (ABI). We also exchange information with other Insurers and other organisations through various other databases. The aim is to help validate information provided and also to prevent fraudulent claims. Under the conditions of your policy, you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. We will pass information relating to this incident to the registers.

Your policy details will be added to the Motor Insurance Database (MID), run by the Motor Insurers’ Bureau (MIB). MID data may be used by the DVLA and DVLNI for the purpose of Electronic Vehicle Licensing and by the Police for the purposes of establishing whether a driver’s use of the vehicle is likely to be covered by a motor insurance policy and/or for preventing and detecting crime. If you are involved in an accident (in the UK or abroad), other UK insurers and the Motor Insurers’ Bureau may search the MID to obtain relevant document information. Persons pursuing a claim in respect of a road traffic accident (including citizens of other countries) may also obtain relevant information which is held on the MID. You can find out more about this from us or at www.mib.org.uk.

Your information (including any personal and sensitive information you have given) may also be disclosed to agents and service providers appointed by us (such as claims handling agents, approved engineers, and investigative agents) and may be transferred to any country including countries outside the European Economic Area for the purposes of administration. Your information may also be shared with other members of QBE Insurance Group.

Declaration: By clicking on the submit button (below) I/We hereby declare that the above information and statements are true to the best of my/our knowledge and belief and I/We have not withheld any material information. I/We understand that you may ask for information from other Insurers to check the answers I/We have provided. No other insurance is in force and I/We will render all assistance required by QBE Insurance (Europe) Ltd or their agents or service providers appointed on their behalf.

I/We also agree to QBE Insurance (Europe) Limited processing and disclosing my/our personal and sensitive information and I/We have read and understood the above notice and declaration.

QBE Insurance (Europe) Limited is part of QBE European Operations, a division of the QBE Insurance Group. QBE Insurance (Europe) Limited is authorised and regulated by the Financial Services Authority. Registered office Plantation Place, 30 Fenchurch Street London EC3M 3BD. Registered in England and Wales No. 1761561