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Accident form

Accident form

Accident Evidence & Insurer Notification Form

Mobile-friendly so you can use it at the roadside. Evidence-heavy and insurer-friendly. We capture the customer's authority, third-party details and an audit trail; insurers retain the right to investigate liability and policy cover.

0330 043 3409

24/7 UK dispatch
£0 upfront cost
Independent engineer
Like-for-like replacement

24/7

UK response

Recovery dispatch and live claim handlers, 365 days a year.

UK cities

45+

Direct coverage

Response

<60m

First contact SLA

Cost

£0

Upfront to driver

Customer details8%

1. Customer details
2. Customer vehicle
3. Accident details
4. Accident description
5. Collision & impact
6. Third-party driver details
7. Optional TP statement
8. Witnesses
9. Passengers
10. Vehicle damage
11. Authorities (recovery, storage, repair, hire)
12. Consent (injury, authority, data, marketing)
13. Final declaration & sign

Accident Evidence & Insurer Notification Form

Important notice before signing

This form is used to record accident facts, vehicle damage, Third-Party Driver details, evidence, Claimant authority, consent and any voluntary Third-Party Driver statement. It may be provided to insurers, repairers, recovery operators, storage providers, engineers, credit hire providers and authorised legal partners where necessary. This form does not bind any insurer. Insurers may still investigate liability, policy cover, causation, fraud concerns, vehicle position, witnesses, dashcam footage, CCTV and the circumstances of the accident. Personal injury claims are not handled in-house by CityGrip Accident Claims unless the correct authorisation and compliance structure is in place. Injury enquiries may be referred only with separate consent to an authorised solicitor or regulated partner.

1. Claimant details

Who you are and how we should reach you. Fields marked * are required. Fields marked Recommended are strongly encouraged - they help your claim move faster.

Full name*

Date of birth*

Postcode*

Home address*

Phone number*

Email address*

Preferred contact method*

Occupation*

Employment status*

Driving licence held*

Licence categoryRecommended

e.g. B for cars, A for motorcycles. Helps the insurer match you to your policy.

Any driving restrictions?Recommended

2. Claimant vehicle details

Make, model, year, colour and registration are required so we can identify your vehicle to insurers and recovery operators.

Vehicle registration*

Make*

Model*

Year*

Colour*

MileageRecommended

Helps the engineer value your vehicle if it's a total loss.

Registered keeper*

Vehicle owner*

Financed, leased or rented?*

Finance / lease company

Only if financed/leased

Insurance provider*

Policy number*

Type of cover*

Vehicle use*

Roadworthy before the accident?*

Any pre-existing damage?*

Pre-existing damage description

Only if there's pre-existing damage

3. Accident details

Insurers will rely on this section. Please complete every required field accurately.

Date of accident*

Time of accident*

Exact location*

PostcodeRecommended

Pinpoints the scene for recovery and insurer dealings.

What3WordsRecommended

Three-word location code - very useful if recovery is needed.

Road name*

Town / city*

Direction of travel (customer)*

Approximate speed (mph)*

Customer vehicle was…*

Lane position*

Weather*

Road condition*

Traffic condition*

Traffic lights / signs involved?*

Roundabout / junction involved?*

Motorway involved?*

Police attended?*

Police reference numberRecommended

Only if police attended. Insurers rely heavily on this when liability is disputed.

Ambulance attended?*

Fire service attended?*

Anyone injured?*

Vehicle driveable after accident?*

Recovery required?*

4. Accident description by Claimant

In your own words, describe what happened. Take your time - clear detail here helps your insurer accept the claim.

Please cover:

Where you were positioned and which direction you were travelling
What the Third-Party Driver did just before the accident
Where on your vehicle the impact happened
Whether the Third-Party Driver admitted fault at the scene
Whether anyone else saw the accident (witnesses)
Whether dashcam, CCTV or shop cameras might have recorded it

Your description*

5. Collision type, point of impact & photos

Tick everything that applies. The more boxes you tick, the easier it is for the insurer to picture the accident.

Claimant vehicle was - tick all that apply

Hit from the rearHit from the frontHit on driver sideHit on passenger sideParked and unattendedStationary in trafficTurning leftTurning rightChanging laneOn a roundaboutExiting a junctionEntering a junctionReversingHit by opening doorHit by uninsured driverHit and runOther

Third-Party Vehicle was - tick all that apply

Travelling behind ClaimantTravelling in front of ClaimantChanging laneReversingPulling out from side roadEntering roundaboutExiting roundaboutOvertakingOpening doorParkedUnknown

Claimant vehicle impact area - tick all that apply

Front bumperRear bumperBonnetBoot/tailgateDriver front wingPassenger front wingDriver doorPassenger doorRear quarterWheel/suspensionWindscreen/glassAirbags deployedOther

Third-Party Vehicle impact area - tick all that apply

Front bumperRear bumperDriver sidePassenger sideWheel/suspensionUnknownOther

Damage photosRecommended

Photos of every damaged area. The single most important piece of evidence for an insurer.

Scene & road layoutRecommended

Wide shots showing the road, junction, signs and lane positions.

Dashcam / CCTVRecommended

Clips or stills if you have them. CCTV from a nearby shop counts too.

Police paperworkRecommended

Photo of the police card or any reference number paperwork.

Files are stored encrypted and only accessible to authorised staff via signed URLs.

7. Third-Party Driver details

Only record what the Third-Party Driver voluntarily shares. The more they give, the stronger the claim. Don't ask for ID documents or full licence/policy copies unless a solicitor or insurer specifically requests them later.

Third-Party Driver full nameRecommended

Third-Party Driver home addressRecommended

Third-Party Driver phoneRecommended

Third-Party Driver emailRecommended

Third-Party Vehicle registrationRecommended

Third-Party Vehicle make / modelRecommended

Third-Party Vehicle colourRecommended

Third-Party Driver's insurerRecommended

Third-Party Driver's policy numberRecommended

Registered owner (if different from driver)

Was the Third-Party Driver also the owner?Recommended

8. Optional Third-Party Driver Statement

Optional. The Third-Party Driver only fills this in if they're happy to. If they sign, it becomes a written admission insurers can rely on.

Notice to the Third-Party Driver

You do not have to complete this section for CityGrip Accident Claims. You may contact your own insurer before signing. You should only sign if the information is true and accurate. This statement may be shared with insurers and may be used as evidence. It does not bind your insurer and does not prevent your insurer from investigating the accident.

Third-Party Driver's account of the accidentRecommended

Third-Party Driver responsibility - tick one only

Based on my own understanding, I believe I was responsible for the collision.Based on my own understanding, I believe I contributed to the collision.I do not admit responsibility, but I confirm the factual details I have provided are true.I am unsure and will leave liability to the insurers.

Reason or factual explanationRecommended

Third-Party Driver declaration

I confirm that I am voluntarily providing this statement. I have not been pressured, threatened, rushed or misled. I believe the facts I have provided are true and accurate to the best of my knowledge. I understand that this statement may be shared with the parties' insurers and may be used as evidence in connection with this accident. I understand that insurers may still investigate liability, policy cover, causation, fraud concerns and the circumstances of the accident.

I confirm I am voluntarily providing this statement and that the facts I have given are true to the best of my knowledge.

Third-Party Driver printed full name

Third-Party Driver signature

Device, IP address and timestamp are captured automatically with this signature (Electronic Communications Act 2000, s.7).

Date signed

Time signed

9. Witness details

If anyone independent saw what happened, their details and statement carry real weight when liability is disputed.

Witness full nameRecommended

Witness phoneRecommended

Witness emailRecommended

Witness address

What did the witness see?Recommended

Witness consent

I agree that my contact details and statement may be shared with insurers, authorised legal partners or relevant parties dealing with this accident.

The witness agrees that their contact details and statement may be shared with insurers and authorised parties.

Witness signature (optional)

Date

Time

10. Passenger details

Anyone who was inside your vehicle when the accident happened. Skip if you were alone.

Passenger nameRecommended

Passenger phoneRecommended

Passenger email

Seating positionRecommended

Any injury reported?Recommended

The passenger consents to being contacted about this accident.

11. Vehicle damage and roadworthiness

Tells us whether the vehicle is driveable and what the recovery operator needs to know.

Can the vehicle start?*

Can the vehicle drive?*

Is it safe to drive?*

Airbags deployed?*

Fluid leak?*

Wheel damage?*

Suspension damage?*

Steering affected?*

Warning lights showing?*

Door / boot / bonnet stuck?Recommended

Recovery required?*

Storage required?*

Preferred repair locationRecommended

Where you'd like the vehicle repaired (we'll match a partner garage if you don't have a preference).

Current vehicle location*

12-15. Authorities - recovery, storage, repair & replacement vehicle

Tick whichever you'd like CityGrip to coordinate on your behalf. Your single signature on the final step authorises every box you tick here.

Recovery authority

I authorise Citygrip LTD, trading as CityGrip Accident Claims, to arrange accident recovery for my vehicle where required.

Pickup locationRecommended

Drop-off / storage locationRecommended

Vehicle condition before recoveryRecommended

Keys available?Recommended

Vehicle rolls?Recommended

Wheels damaged?Recommended

Special equipment neededRecommended

I authorise CityGrip Accident Claims to act on the “Recovery authority” above.

Storage authority

I authorise CityGrip Accident Claims or its appointed storage partner to store my vehicle where necessary after the accident. I understand storage may be charged daily and may be submitted to the at-fault insurer where appropriate. I understand that storage must remain reasonable and necessary, and that my file should be reviewed regularly to avoid unnecessary delay.

Storage start (date / time)Recommended

Storage locationRecommended

Daily storage rate

I authorise CityGrip Accident Claims to act on the “Storage authority” above.

Repair and engineer authority

I authorise CityGrip Accident Claims to arrange or coordinate vehicle inspection, engineer assessment, repair estimate and repair referral where appropriate.

Preferred repairerRecommended

Engineer inspection required?Recommended

Repair estimate required?Recommended

Total loss suspected?Recommended

I authorise CityGrip Accident Claims to act on the “Repair and engineer authority” above.

Replacement vehicle / credit hire screening

Replacement vehicle support is not guaranteed. It depends on need, eligibility, evidence, liability position and insurer assessment. I understand that any replacement vehicle or credit hire arrangement must be reasonable, necessary and proportionate. I understand that insurers may challenge the need for hire, daily rate, vehicle type and hire period.

Need a replacement vehicle?Recommended

Why do you need it?Recommended

Have access to another vehicle?Recommended

Can use public transport?Recommended

Has your insurer offered a vehicle?Recommended

Has the Third-Party Driver's insurer offered a vehicle?Recommended

Was it suitable?

Reason unsuitable

Vehicle requiredRecommended

Like-for-like required?Recommended

Reason

Driving licence categoryRecommended

Any points / convictions?Recommended

I authorise CityGrip Accident Claims to act on the “Replacement vehicle / credit hire screening” above.

16-19. Consent - injury referral, authority to act, data sharing, marketing

Each consent below is recorded separately, in line with UK GDPR Article 7 (data) and PECR (marketing).

16. Injury screening & referral

CityGrip Accident Claims does not handle personal injury claims in-house. If you'd like help with an injury, we'll only refer you to an authorised solicitor or regulated injury partner if you tick the separate consent below - it is your choice.

Was anyone injured?Recommended

Medical attention received?Recommended

Symptoms reported

Would you like a referral to an authorised injury partner?

Separate injury referral consent

I expressly consent to Citygrip LTD, trading as CityGrip Accident Claims, sharing my contact details, accident details and relevant injury information with an authorised solicitor or regulated injury claims partner for the purpose of contacting me about a possible personal injury claim. I understand I am free to choose my own solicitor and that any solicitor or regulated partner must provide their own client care, funding terms and regulatory information.

I expressly consent to my details being shared with an authorised solicitor or regulated injury claims partner for the purpose of contacting me about a possible injury claim.

17. Claimant authority to act

I authorise Citygrip LTD, trading as CityGrip Accident Claims, to contact and communicate with the parties I tick below for the purpose of assisting with accident-related vehicle damage, recovery, storage, repair coordination, engineer inspection, replacement vehicle screening, insurer communication, invoice submission, evidence sharing and authorised partner referral where applicable. I understand CityGrip Accident Claims is not a solicitor firm and does not provide legal advice.

I authorise CityGrip to contact:

My insurerThe Third-Party Driver's insurerRecovery operatorStorage providerRepairer / bodyshopEngineer / vehicle assessorCredit hire / replacement vehicle providerAuthorised solicitor / legal partnerRegulated injury claim partner (only with separate injury consent above)

I agree to the Customer Authority to Act above. (Required)

18. Data sharing consent (separate - UK GDPR Article 7)

I consent to Citygrip LTD, trading as CityGrip Accident Claims, sharing relevant information from this accident file where necessary with insurers, recovery operators, storage providers, repairers, engineers, credit hire partners and authorised legal partners. I understand only relevant information should be shared for the stated purpose.

I consent to relevant information being shared as described above. (Required)

19. Marketing consent (separate - PECR, opt-in only)

This is optional and separate from accident support consent. I understand I can refuse marketing consent and still use the accident support service.

Channels (none pre-ticked)

Email marketingSMS marketingWhatsApp marketingPhone marketing

You can withdraw marketing consent at any time. See our privacy policy.

20. Claimant final declaration

Read the declaration below, tick once to agree, and sign once. That single signature applies to every authority and consent you ticked on the previous step (Authority to Act, Data sharing, Marketing, Recovery, Storage, Repair, Hire and Injury referral).

Claimant final declaration

I believe the information I have provided in this form is true and accurate to the best of my knowledge and belief. I confirm that I have had time to read and understand this form. I have not been pressured, threatened, rushed or misled. I understand that knowingly giving false or misleading information may have serious consequences, including rejection of the claim, recovery of costs, cancellation or voiding of insurance and referral to fraud prevention agencies or law enforcement. I understand that this form may be relied upon as evidence in insurer correspondence, dispute resolution, pre-action correspondence or legal proceedings connected with this accident. I understand that if formal court proceedings are later required, I may be asked to sign a separate witness statement or legal document using the required court wording. (Civil Procedure Rules Part 22 sets out when formal statements of truth are required and the wording used for court documents and witness statements.)

I have read and agree to the Customer Final Declaration above. My signature below verifies this declaration. (Required)

Claimant printed full name*

Claimant signature

Required. Your electronic signature has the same legal effect as a wet-ink signature (Electronic Communications Act 2000, s.7). It will be applied to every authority and consent you ticked on the previous step. Device, IP address, timestamp and form/consent version are captured automatically with your signature.

Date*

Time*

What happens next

Your submission is recorded with a unique reference, timestamp, IP address, device, form version and consent version.
A signed PDF copy is generated and downloaded to your device.
We begin coordinating recovery, storage, repair and insurer communication for any authority you ticked.
Injury enquiries are referred only with your separate consent above.

Step 1 of 13 - Customer details

Before you start

• Make sure everyone is safe.
• Call 999 for injuries or blocked carriageways.
• Get the third-party registration and insurance details.
• Take wide and close-up photos of the scene.
• Ask any independent witnesses for contact details.

We do not provide legal advice. Personal injury enquiries are referred only with your consent to authorised legal or regulated partners.

Calls may be recorded for quality and compliance purposes. A notice is given at the start of recorded calls.