Accident report form
Accident report form
Step 1 of 10 - Your details
Address Line 2
State / Province / Region
ZIP / Postal Code
Date of birth
Type of licence
Provisional licence plus CBT
Full car licence plus CBT
Full car licence obtained before 1 February 2001
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.
Please provide names, addresses and telephone numbers of witnesses.
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.
Brief purpose of journey
GreenMo scooter number
Please enter a value less than or equal to
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.
If there is anything else which you think might be relevant, please include it below
I declare that the information given in this form is true and correct to the best of my knowledge and belief