Register | Accident Management System

Details of Insured Company

Insured's Reference

Capulus Reference

Policy Number

Insured's Name

Address

Postal Code

Tel no.

Subsidiary or Depot / location code

Details of Insured Driver

Name *

Occupation *

Company Name *

Address *

Postal Code *

Tel no. *

Contact Telephone Number of different from above

Age *

Licence type *

Licence Number *

How Long Held (Years) *

Any convictions? *

Conviction Details

Details of Insured Vehicle

Registration No. *

Make *

Model *

Manufacture Year *

Are you claiming repair under the policy? *

Yes No

Details to Any Damage to the Vehicle *

Brief description of damage to vehicle *

Details of Accident

Date *

Time *

Weather Condition *

Condition of Road Surface *

Location of Accident (Full Address) *

What lights were showing on your vehicle?

What lights were showing on other vehicle?

If police were involved give officer's number and station

Please give details of any warning / prosecutions pending against any party

Speed of Vehicle - Before Impact *

Speed of Vehicle - After impact *

Did any body sound their horn? *

Yes No

Details of other Vehicles Involved / Property Damaged

1)Name and address of driver / property involved *

Postal Code *

Tel no. *

Make *

Model *

Registration Number *

Vehicle Colour *

Insurer

Policy Number

Apparent Damage *

Owner of Vehicle of Different if above?

# of people in vehicle( including driver) *

2) Name and address of driver / property involved

Postal Code

Tel no.

Make

Model

Registration Number

Vehicle Colour

Insurer

Policy Number

Apparent Damage

Owner of Vehicle of Different if above?

# of people in vehicle( including driver)

Details of Persons Injuried (including fatalitites)

1) Name and address of Injuried

Postal Code

Tel no.

Injuries

Travelling in which vehicle?

Any treatment administered?

Hospital to which taken?

Detained

2) Name and address of Injuried

Postal Code

Tel no.

Injuries

Travelling in which vehicle?

Any treatment administered?

Hospital to which taken?

Detained

Witnesses (including passengers in your vehicle)

1) Name of witness

Address

In a Vehicle

Yes No

# of Passengers in Vehicle

Ask if any witness's

Postcode

Tel No.

2) Name of witness

Address

In a Vehicle

Yes No

# of Passengers in Vehicle

Ask if any witness's

Postcode

Tel No.

Plan of accident (showing road markings, signs and directions of travel with measurements if known)

Plan of accident *

Circumstances of accident (state fully what happened)

Circumstances *

Upload Pictures*

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Upload Video*

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Signing Declaration

Drivers name *

Geo Stamp Location *

Digital Signature *

I declare these details to be true