Report any damage immediately to Shropshire Wheels 2 Work on 01743 237885. You must complete this form in as much detail as possible and send it us. If you can, make a copy for your own records. If your moped has been damaged you must not ride it until it has been checked over by Fast Trak. /
1) / Your details
Name / Moped Registration
2) / Incident details
a) / Date of Accident / Time of Accident
b) / Location, giving town and road names
c) / Did your mopeds brakes, steering, tyres or any other parts fail? If yes give details.
d) / Before the accident what was the speed of: / Your vehicle / The other vehicle(s)?
e) / What lights were being shown by: / Your vehicle / The other vehicle(s)?
f) / What warning signals were being given by: / Yourself / The other vehicle(s)?
g) / What was the state of the weather?
h) / What was the state of the road surface?
i) / What was the speed limit? / Were the street lights on?
j) / Who or what in your opinion was the cause of the accident?
k) / Did anyone say it was their fault (admit liability?)No / Yes (give details below)
What did they say?
l) / Give full details of what happened in the accident
n) / Draw a sketch plan showing road names, widths, markings, traffic signs and warnings. Indicate positions and directions of vehicles.
o) / Describe the damage caused to your moped.
p) / Indicate the area of damage and direction of impact.
3) / Were there other vehicles involved? No/ Yes (give details below, repeat spare sheet if more than one vehicle involved )
Name of driver/owner / Phone no.
Address
Insurance company and policy number
Their vehicle registration / Make, model and colour
Describe the damage to their vehicle
4) / Was anyone injured? No / Yes (give details below)
Name / Age / Injury details / Taken to hospital? / Wearing a seatbelt?
5) / Was any other property or animals involved? No / Yes (give details below)
Type of property or animal / Name and address of owner / Damage or injury
6) / Did anyone witness the accident?No/ Yes (please give details below)
Name / Address / Age
7) / Have the police been involved? No/ Yes (if yes give details)
Reference no.
Name of Officer / Station
I confirm that the details on this form are true to the best of my knowledge and ability and will be used where necessary by Wheels 2 Work e.g. to complete an insurance application.
Name / Date
Signature
Please return this form to Wheels 2 Work, 4, The Creative Quarter, Shrewsbury Business Park, Shrewsbury SY2 6LG or email to