Pegasus Accident Questionnaire
Please complete all sections of this form before continuing your route.
Complete while at the accident scene.
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Firstly, take photos of all damage to vehicle/s involved.
Take photos of scene of accident. (Any images that can assist the claim)
Get the other drivers contact details (Driver Name ,Address and Phone Number).
Make sure you take a picture of the vehicle registration number
Get the name of the other vehicle driver insurance company.
If witnesses are present – take down their details ( Name , Address, Phone Number
Provide the other driver with these detais:
Pegasus Couriers
Scotland Limited Website:
www.pegasuscouriers.co.uk
Insurer: United Legal
United Legal:
01414738284
United Legal email:
claims@united-legal.co.uk
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Policy Holder
Address/Post Code
Policy No
VAT registered?
Claim Number
*
Claim Number
Depot you are based at:
*
NEH
DAB
DEH
DXG
DBT
YODEL
Evri
Choose the depot you work from
Vehicle make / Model/ GVW
*
Vehicle make / Model/ GVW
Registration number
*
Registration
For what purpose was the vehicle being used at the time of the accident?*
*
Nature of the trip
Name of driver in charge of vehicle
*
Date of birth
Address
*
Address Line 1
City
State / Province / Region
Postal Code
Phone number:
*
Email
*
Class of licence*
*
It states the class on the licence.
Date passed driving test for vehicle driven
*
Date passed driving test - should be on the licence
Groups / categories covered on licence*
*
Photo of front of driving licence
*
Use Mobile and take a photo of the front of driving licence. Make sure all the corners are in the frame
Photo of back of driving licence
*
Use Mobile and take a photo of the back of driving licence. Make sure all the corners are in the frame
Give details of any physical defect, infirmity, defective vision or hearing. if none, please state 'none'*
*
Give details of any physical defect - if none, state None.
Give details of all motoring convictions or prosecutions pending (i.e. charge: date: penalty). if none, please state 'none'*
*
Date of penalty
Date of penalty
Have you had any accident, loss ( incl. fire or theft) in last 5 years.
*
Have you had any accident, lost in last 5 years.
Next
Details of Accident
Details of Accident.*
*
Who do you feel was responsible - we are not on the scene! Please provide as much detail as possible so we can have a clear picture of what happened!
Exact location
*
Address Line 1
City
State / Province / Region
Exact location
Date and time of Incident
*
Date
Time
Date and time of Incident
Speed your vehicle was travelling
*
Speed your vehicle was travelling
Weather conditions
*
Weather conditions
Who do you feel was responsible and why?
*
Who do you feel was responsible - we are not on the scene! Please provide as much detail as possible so we can have a clear picture of what happened!
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ONLY COMPLETE FOR THEFT OR ATTEMPT THEFT
Was there a theft or attempted theft.
Yes
No
Ignore if there was no theft or attempted theft
Exact location
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Exact location of incident
Date and Time of incident
Date
Time
Estimate to the best of your knowledge
Details of Theft / Attempted Theft
Ignore if there was no theft or attempted theft
What Security/ protection was fitted to the vehicle and were they in use when the incident occurred
Was the vehicle locked and keys removed?
Yes - the vehicle was locked and keys removed
No- the vehicle was not locked and keys removed
Next
Please describe the full damage to your vehicle
Must be completed in all cases
Please complete in all cases. Please describe the full damage to your vehicle
*
Photos of damage
Drag & Drop Files,
Choose Files to Upload
Please use your mobile phone to upload the pictures or a video. If this fails, or the video is too large, please send via email to
Next
Please describe the full damage to your vehicle
Must be completed in all cases
Was another Vehicle involved ?
*
Yes - another vehicle was involved in the accident
No - another vehicle was NOT involved in the accident
Vehicle Make
Details of the other vehicle
Vehicle Model
Details of the other vehicle
Colour
Details of the other vehicle
Registration
Details of the other vehicle
Name of driver
*
First
Last
Details of the other vehicle driver
Phone number of driver
Details of the other vehicle driver
Address
Address Line 1
City
State / Province / Region
Postal Code
Details of the other vehicle driver
There insurance company
*
Details of the other vehicle driver
Any relevant photos
Next
Injured Party Details
Was anyone injured ?*
*
Yes - someone was injured on the scene
No - no one was injured on the scene
Name
*
First
Last
Address
Address Line 1
City
State / Province / Region
Postal Code
Describe the injuries the person(s) allegedly sustained from the accident
Injuries the person(s) allegedly sustained from the accident
State the Police Station details and Address as well as the Reference Number. Also supply the officials numbers and state if anyone was cautioned
State the Police Station details and Address as well as the Reference Number. Also supply the officials numbers and state if anyone was cautioned
Witnesses? If so, please advise name & address and if they were a passenger in your vehicle or known to you or the driver
Next
Declaration
I declare that to the best of my knowledge and belief, the details given are accurate. I understand that if fraudulent means, including inflation or exaggeration of the claims, are used, all benefits under the Policy shall be forfeited, and criminal proceedings may ensue. If the vehicle is beyond repair, I authorise removal to safe storage, subject to Policy Cover. I authorise you/your solicitors on my behalf to make enquiries/admissions/settlements and give consents as may be considered necessary for the disposal of such claims and litigation arising.I authorise the release of my DVLA records. I understand you may seek information from other Insurers to check my answers.
Insurers pass information to the Claims and Underwriting Exchange Register, run by Insurance Database Services Ltd (IDS Ltd) and the Motor Insurance Anti-Fraud and Theft Register, run by the Association of British Insurers (ABI The aim is to help us to check the information provided and also to prevent fraudulent claims. Under the conditions of your Policy, you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. We will pass information relating to this incident to the registers.
Signature
Clear Signature
Name
*
First
Last
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