For Manager Use (complete on receipt)

RMS

CJP Claim No

Driver & Vehicle

Driver Name & Surname *

ID No *

Truck Reg No *

Trailer Reg No

Other Vehicle Reg No

Other Trailer Reg No

Incident Details

Date *

Time *

Weather

Speed travelling (km/h)

From

To

Exact Location of Incident

GPS Coordinates

Pin GPS

Other Party & Authorities

Name of Other Party

Other Party ID No

On-scene Police Officer Name

Police Officer Contact No

Police Station

Case No

Witnesses (names and contact numbers)

Goods

Description of Goods on Truck

Damaged Goods

What happened to damaged goods at the scene?

Description

Short Description of Accident

Other Relevant Information

Scene Photos (0/4)

Add photo

Sketch of Accident

Clear

Driver Signature

Clear

Date

Download PDF Submit & Send via WhatsApp