Motor Vehicle Accident Claim Form Page 3
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47. Particulars of Accident
1. Date
Day
Time
am/pm
/
/
Place
2. Please describe
(a) Where you had been and where you were going
(b) The width of the street
(c) Your position on it
(d) Your speed just prior to impact
kph
(e) The other party’s speed just prior to impact
kph
(f) Warning signals given by either party
(g) Who do you consider was responsible for the accident
(h) Your reasons for thinking the other party was to blame
(i) The name and address of that other person
(j) The other vehicle
(a) Registration
(b) Make
(c) Model
3. General description of accident
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