Collision/Incident Information Form

The Traffic Collision/Incident

Please state your involvement in the collision?

Your Location (I.e. Road, Motorway)

Town Location

County Location

Collision/Incident Subject

Describe the Collision/Incident in your own words

Registration of Vehicle involved in Collision/Incident

What date did the Collision/Incident take place?*

What time did the Collision/Incident take place?*

Was the traffic like?:

Was the weather like?:

Photos of Traffic Collision/Incident

Photo 1

Photo 2

Your Details

Your Name (required)

Your Company

Your Email (required)

Your Telephone

Any Injuries?

If you were injured in the collision, please give details of your injuries:


Would you like a copy of this report?*

Are you willing to give your details to the Police?*