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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

 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