Motor Trade Accident Statement of Fact

You will need:

– Driving Licence Code. This can be found at https://www.gov.uk/view-driving-licence and requires you to input your driver number and national insurance number in order to generate the unique code.
– Copy of V5
– Evidence of Motor Trade activity
– Trading Accounts
– Purchase Receipts
– Sales Receipts

Get Licence Code

1 Step 1

Section One - Policyholder

Name

Date of Birth

Trading Title

Private Address

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Business Address

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Full Time Occupation

Any Part Time Occupation

Please provide documentary evidence of involvement in the Motor Trade (e.g. copy of trading accounts)

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Private Tel

Business Tel

Mobile Tel

Policy No.

Broker

Section Two - Driver (or last permitted driver) details

Namefull name

Dateof Birth

Address

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F-T Occupation

P-T Occupation

Private Tel

Business Tel

Mobile Tel

Licence No.

Date Test Passed

Relationship to Policyholder

Please give details of all previous convictions including non-motoring convictions (which are not spent) any convictions pending and any County Court Judgments. If none, state none.

Date of Conviction	Conviction Type and Circumstances	Fine / Sentence
			×
			×

(2)

Paste copy of your unique DVLA code.Please supply photo ID and the unique code to view and secure a copy of your license history from the DVLA. This can be found at https://www.gov.uk/view-driving-licence and requires you to input your driver number and national insurance number in order to generate the unique code. Please paste the unique code which has a one time access within a 21 day time period below.

Driving licence photo ID

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Give details of any physical defects or infirmities

Has Insurance ever been cancelled or refused?If yes, provide details

If yes, give insurers details

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Please give details of previous accidents/claims/losses. If none, state none.

Date of Incident	Circumstances	Cost
			×
			×

(2)

Section Three - usage of vehicle

State the exact use of the vehicle at the time of the incidentThe words BUSINESS / PLEASURE are not sufficient.

State exact details of journey.

Travelling from

Travelling to

If yes, give particulars and details of Goods in Transit and Goods in Transit insurers

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How many passengers were being carried?

Provide details of passengers

Name	Address	Contact Number
			×
			×

(2)

Section Four - Particulars of vehicle / ownership

Vehicle Make / Model

Registration Number

Date of Registration

Engine Size

Colour

Mileage

Current Value

Date of Purchase

Price Paid

Expiry Date

If yes, give full details

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If yes, give full details

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Give details of any recent repair / maintenance work on the vehicle

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If no, please state the details of the registered owner of the vehicle.

Name

Relationship to Policyholder

Address

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Telephone No.

Give details of any HP or finance company interest in the vehicle

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Timevehicle came into your possession

Datevehicle came into your possession

For what purpose was the vehicle in your possession?

When were you due to hand back the vehicle?

What work had been carried out on the vehicle?

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If yes, please clarify the following.

Who paid for the vehicle?Insured / Named Driver / Other

What is their relationship to the vendor?(if any)

If log book is not in the vendors name state reason, if known

Upload V5 and sales receipt (if the vehicle has been sold)

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Section Five - The accident scene

Accident Date

Accident Time

Locationyou can type the rough address and specify further by dragging the pin on the map

Distance from trade premisesif applicable

If incident occurred on premises state type of property

Weather and road conditions

What was the speed limit in force?

What road signs and markings were there?

What was the width of the road?

Speed of insured vehicle prior to incident

Speed of third party vehicle prior to incident

Distance of insured vehicle from near side kerb

Distance of third party vehicle from near side kerb

What lights were displayed by the insured vehicle?

What lights were displayed by the third party vehicle?

What signals were given by the insured vehicle?

What signals were given by the third party vehicle?

What warnings were given by the insured vehicle?

What warnings were given by the third party vehicle?

Section Six - Accident description and diagram

Who was to blame for the incident in your opinion?

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Please provide a detailed explanation of exactly how the incident occurred

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Please upload a sketch of the road(s) showing the position of the vehicles at the point of impact. Indicate direction and track by arrows. Please show road signs and markings, pedestrian crossings and direction of nearest towns.

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Section Seven - Damage to your vehicle

If comprehensive cover please upload two competitive estimates

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Describe damage to vehicle

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Upload any images showing damage to the vehicle

Upload

If you have not received a quote what is the estimated cost of repair

Where can the vehicle be inspected?

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When can the vehicle be inspected?

Name of repairer

Address of repairer

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Telephone

Section Eight - Third Party Details

Damage to other vehicles and property not owned by you or in your custody or control

Make of vehicle and Registration Number	Damage Details (state if vehicle was mobile after incident)	Name / Address /Tel Number of owner and / or driver	Name and Address of Insurer	Policy Number
					×
					×

(2)

Details of Injuriesincluding to your passengers

Name / Address and Telephone Number of Injured person	Approx Age	Nature of Injuries	Specify if own passenger / TP passenger / pedestrian	Was seat belt worn?
					×
					×

(2)

Give name and address of Hospital

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Please provide details

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Please upload any third party correspondence, notice of prosecution or other proceedings.

Upload

Section Nine - Police Details

If yes, please provide the name and address of station.

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Police Incident reference

If yes, give details

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Section Ten - Witness Details

Please provide details of all passengers and independent witnesses.

Name / Address of own passengers	Name / Address of any other witnesses
		×
		×

(2)

Section Eleven - Additional Information

Please provide any additional information which may be helpful to us in dealing with your claim.

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Section Twelve - Declaration

Please read carefully before signing

I hereby confirm that the above information is a true and accurate statement. Unless Red Seal Resources hear from you to the contrary within the next 24 hours the above contained information will be deemed to be a true and accurate record of events.

I declare that the above statements are true and correct to the best of my knowledge and belief. I hold no other policy in addition to this one indemnifying me in respect of this claim. I have not withheld from the Insurers any information with my knowledge connected with the loss and I agree to provide the Insurers with any further information or documentation as may be required. I hereby confirm that Red Seal Resources Ltd have my authority to recover any outlays on my behalf for monies paid under this contract of insurance in relation to this event. If my vehicle is a total loss I agree that the company may have my permission to remove the vehicle to safe and free storage pending settlement of this claim. I understand that any attempt to make a fraudulent claim may result in prosecution.

Signatureof driver or last person in charge of vehicle

Signatureof Policyholder

Dateagreed

Agreement

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