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It is an offence to make a false statement on this document
Vehicle Accident/Damage Report
For Office Use: Flare Number
LOCAL GOVERNMENT (MISCELLANEOUS PROVISIONS) ACT 1976 (“the Act”)
SECTION 50(3) NOTIFICATION
Without prejudice to the provisions of section 25 of the Act of 1972, the proprietor of a Hackney Carriage or of
a Private Hire vehicle licensed by a district council shall report to them as soon as reasonably practicable,
and in any case within seventy two hours of the occurrence thereof, any accident to such hackney carriage
or private hire vehicle causing damage materially affecting the safety, performance or appearance of the
hackney carriage or private hire vehicle or the comfort or convenience of persons carried therein, (failure to
do so is an offence and will result in action being taken against you).
• If you are completing this form by hand please write clearly in block capitals
• In all cases ensure that your answers are inside the boxes and written or typed in Black ink.
• Please keep a copy of the completed form for your records.
SECTION A – THE NOTIFIER
Badge Number Not a licensed driver
Full Name Mr/Mrs/Miss/Ms
day month year
Date of Birth
Home
Address
Postcode
Tel No Fax
Mobile No
Email
I was driving the vehicle when the accident happened
The person below was driving the vehicle when the accident happened
SECTION B – THE DRIVER
Badge Number
Full Name Mr/Mrs/Miss/Ms
day month year
Date of Birth
Home
Address
Postcode
Tel No
Fax
Mobile No
Email