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Graham's story
Total Van Assist Accident Report
Report your accident and get immediate help
The form below gives you the power to tell us about what's happened in your own words.
Don't worry if there are some boxes you leave blank; just tell us what you can.
About you
Your first name: Address line 1:
Your surname: Address line 2:
Email address: Town/Village:
Home tel: County:
Mobile tel: Post code:
About your vehicle
Vehicle make & model (eg Ford Transit): Vehicle reg plate no.:
Date, time and location of the accident
Date & time of the accident: Location of the accident:
Vehicle damage and physical injuries
Is your vehicle damaged? Yes No Any physical injuries? Yes No
If yes, please describe
the damage to your vehicle
If yes, please describe
the injuries:
About the at-fault party
Is the at-fault party identified? Yes No Is the at-faulty insured? Yes No
If yes, at-fault party's name: If yes, at-fault party's insurer:
At-fault party's other details: the make & model of the vehicle he/she was driving, their vehicle's reg plate number,
their address, etc - whatever you have about the third party, please enter this information below:
About witnesses to the accident, if there were any
Any witness(es) to the accident? Yes No If yes, please tell us about the witness(es) below:
First witness's name: Second witness's name:
First witness's
contact details:
Second witness's
contact details:
About what happened
Please tell us what happened in as much detail as you can:

Assist Protect Ltd is regulated by the Data Protection Act 1998 and is registered with the Information Commissioner's Office under registration reference Z2148051.

Assist Protect Ltd is an appointed agent of One-Stop-Law Limited who are regulated by the Claims Management Regulator in respect of
regulated claims management activities under Authorisation Number CRM27266, details of which can be found at

Registered office: Mercia Place, 2 Main Street, Repton, Derbyshire, United Kingdom, DE65 6EZ Company No. 7184256.

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