Vehicle Incident Form 
TOWN POLICE CLAUSES ACT 1847
LOCAL GOVERNMENT (MISCELLANEOUS PROVISIONS) ACT 1976

						 		

This form must be completed when a vehicle is involved in a collision or incident.  All accidents should be reported to the Council as soon as is reasonably practicable and definitely within 72 hours.  Photographic evidence should accompany this form.

1. Please indicate application detail ( as appropriate)	

Hackney Carriage 	
	
Private Hire 	

2. Existing Vehicle Details 	
PLATE NUMBER:	

EXPIRY DATE :

VEHICLE REGISTRATION NUMBER:

DATE OF FIRST REGISTRATION:

MAKE:
	
MODEL:

COLOUR:
	
NUMBER OF DOORS:

IS THE VEHICLE WHEELCHAIR ACCESSIBLE?                                               YES/ NO *(delete as applicable)

NUMBER OF PASSENGERS* (excluding driver):

*this information MUST correspond with the V5 Registration Document

4. Incident Details 	

DATE & TIME OF INCIDENT:

LOCATION OF INCIDENT:

WAS THE VEHICLE IN USE AT THE TIME?                                                                    	YES/ NO *(delete as applicable)	
IF YES, WAS THE VEHICLE BEING USED AS A HACKNEY CARRIAGE/ PRIVATE HIRE VEHICLE?
	YES/ NO *(delete as applicable)	

PLEASE DETAIL THE INCIDENT, WHAT THE SITUATION WAS/ WHAT HAPPENED/ WHETHER THE POLICE ATTENDED ETC:

	

PLEASE DETAIL ANY DAMAGE TO THE VEHICLE INCLUDING POSITION ON THE VEHICLE AND ANY PHOTOGRAPHS WHICH EVIDENCE THIS:

	

DOES THE VEHICLE NEED TO BE REPAIRED?                       
                                             	YES/ NO *(delete as applicable)	

IS THE VEHICLE BEING WITHDRAWN FROM SERVICE?
	YES/ NO *(delete as applicable)	

PLEASE DETAIL THE COURSE OF ACTION (IF ANY) THAT YOU WILL BE TAKING IN RELATION TO THE REPAIR OF THE VEHICLE:

	

5a.  Applicant Information

TITLE:

SURNAME:

FIRST NAMES: 

HOME ADDRESS:

POST CODE:                	
5b. Contact Information	Please tick preferred method of contact	
Home Telephone Number: 		
Mobile Telephone Number:  		
Email Address: 		
5c. DECLARATION  	

The information that you provide on this form and that obtained from other relevant sources (such as from the insurance company) will be used to record the incident in relation to your Hackney Carriage or Private Hire Vehicle.
 
The personal information that you give us will also be used in a confidential manner to help us monitor our processes.  

We may also use the information if there is a complaint or legal challenge relevant to this process.  We may check the information collected.  

We may also use or pass to certain third parties information to prevent or detect crime, to protect public funds, or in other ways as permitted by law.  

By signing the application form we will be assuming that you agree to the processing of sensitive personal data, in accordance with our registration with the Data Protection Commissioner.

I declare that the information which I have given above is accurate and true. 

Signed: _____________________________________________________________               Dated:     /    /      

Print Name: __________________________________________________________	

FOR OFFICE USE ONLY (Application)	
Incident Form Received: 

	Date:

Officer Initials:	
Vehicle Inspected by Enforcement Officer

YES/ NO *(delete as applicable)

	Date:

Officer Initials:	
Certificate of Compliance Check Required

YES/ NO *(delete as applicable)
	Date:

Officer Initials:	
Further Inspection Required

YES/ NO *(delete as applicable)
	Date:

Officer Initials: