Please note: Any field marked with a * must be completed before the form can be submitted. If at the end you click to submit and you do not see a confirmation message then a field is not completed and will be highlighted with a red frame on the form. EVENT DETAILS Date * Day Day12345678910111213141516171819202122232425262728293031 Month MonthDecJanFeb Year Year20242025 Time (approximate) Location (town/city) * Road name / number * Your direction (north, south, east west, into town, out of town) * WEATHER DETAILS Lighting conditions - None - Daylight Dark Cloudy Sunny Foggy Weather conditions - None - Flooded Raining Wet Damp Windy Snowing Sleeting Icy Frozen Do you think the weather conditions had any effect on the incident, or were the cause of it? Yes No INCIDENT DETAILS Was there contact between the vehicles Yes No If yes, describe the contact between any vehicles and the damage Describe what happened Your speed Our speed (if you are unsure an indication of whether our speed was faster / slower than yours will do) Our vehicle registration Our tanker number Our employee’s name Your vehicle make/model Your vehicle colour Your vehicle registration CONTACT DETAILS Your name * Email-address * Your contact telephone number * Do you need to leave us with insurance details? (Subsidiary boxes for insurers name & policy number if so) Name of any potential witness
