Accident report

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone*
Date of birth*
MM slash DD slash YYYY
Occupation*

Type of licence*
- Provisional licence plus CBT
- Full car licence plus CBT
- Full car licence obtained before 1 February 2001
- Motorcycle licence
Date CBT / car / motorcycle licence passed*
MM slash DD slash YYYY
Details of driving convictions (if any)
Include date, offence code, number of points and amount of fine
- I do not have any driving convictions
Details of disabilities (if any)
- I do not have any disabilities

Were there any witnesses to the accident?
- Yes, there were witnesses (fill in details below)
- No, there were no witnesses (go to next page)
Witnesses are people who were present at the accident and saw what happened. They can include passengers in another vehicle involved in the accident.
Witness details
Please provide names, addresses and telephone numbers of witnesses.

Injuries
Please provide details of any injuries which happened as a result of the accident, including in relation to you. If there were no injuries please click to the next page.

Registration number*
Brief purpose of journey*
GreenMo scooter number*
Please enter a number less than or equal to 999.
Date of accident*
MM slash DD slash YYYY
Time of accident*

: Hours

Minutes

AM/PM
Location of accident*
What speed was your vehicle travelling at?*
Description of damage to your vehicle (if any)
Have you continued to use the vehicle?
- Yes, I am using the same vehicle
- No, I am not using the same vehicle (including if GreenMo have swapped it)
Who in your opinion is to blame?*
- I am to blame
- The other vehicle(s) involved is/are to blame
- Nobody is to blame

Details of the accident
Please include as much information as possible, including road names and who did what. Was it dark or during the day? What was the weather? What were road surfaces like?

Did the Police come to the accident?*
- Yes, the Police came and spoke to the people involved
- Yes, the Police came but did not speak with people
- No, the Police did not come
Details of the Police
Please provide details of the Police officers attending, station number and reference number.
Did the Police witness the accident?*
- Yes, the Police witnessed it
- No, the Police did not witness it
Have you received notice of prosecution?*
- No I have not received notice of prosecution
- Yes I have received notice of prosecution

Were any other vehicles involved?*
- Yes (fill in the fields below)
- No (go to the next section)
Details of the driver / rider of any other vehicle(s) involved
Please provide name, address, telephone number and any other details you have.
Make and model of any other vehicle(s) involved
Registration number of any other vehicle(s) involved
Damage to other vehicle(s) involved
Please provide as much detail as possible
Details of insurer of the other vehicle(s)
Have you received any notice of a claim against you?
- Yes I have received notice of a claim
- No I have not received notice of a claim
Approximate speed of the other vehicle(s)
Details of any passengers in the other vehicle(s), including their gender and where they were sitting

Please upload any files which might be useful. This could include photographs or videos taken at the scene or a sketch of how the accident occurred. You MUST upload at least one photograph of our scooter after the accident, to include any damage.
Hidden
Photograph of our scooter (old - hidden)
Max. file size: 120 MB.
Photograph of our scooter*
You must upload one photograph of the scooter, even if there is no visible damage.
Photo 2
Photo 3
Video 1
Max. file size: 120 MB.
Please note that videos might take some time to upload. If preferable, please email to us.
Video 2
Max. file size: 120 MB.
Please note that videos might take some time to upload. If preferable, please email to us.
Hidden
File (old - hidden)
Max. file size: 120 MB.
If there is anything else which you think might be relevant, please include it below

Declaration*
- I declare that the information given in this form is true and correct to the best of my knowledge and belief
Signature

Accident report form