Accident report

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Phone*

Date of birth*

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*

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*

Time of accident*

:

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.

Photograph of our scooter*

Max. file size: 120 MB.

You must upload one photograph of the scooter, even if there is no visible damage.

Photo 2

Max. file size: 120 MB.

Photo 3

Max. file size: 120 MB.

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.

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

File

Max. file size: 120 MB.

Accident report form