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Vehicle Accident Report
Please fill out the form below to report a vehicle accident.
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6 sections
1
Azergo Employee
To Complete
Full Name *
Please provide your name.
Vehicle Registration Number *
Please provide the registration number.
2
Third Party Involved
To Complete
Yes
No
Please select an option.
Full Name
Phone Number
Email Address
Registration Number
Accident Report Form
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Gallery / File
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3
Date, Time and Description of Events
To Complete
Date of Accident *
Please provide the date of the accident.
Time of Accident *
Please provide the time of the accident.
Location of Accident *
Please provide the location of the accident.
Description of Events *
Please describe the events.
4
Type of Damage
To Complete
Physical (Injuries)
Material (Damage)
Please select a damage type.
People Affected and Injuries
⚠ In case of injury, immediately contact 15 (Emergency) or 112 (Emergency Services) for medical assistance.
5
Photos and Documents
Photos of Damage
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Gallery / File
photos, PDF, Word…
Driver's License — Yours
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Gallery / File
photos, PDF, Word…
Driver's License — Third Party
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Gallery / File
photos, PDF, Word…
6
Submit Report
To Complete
Recipients:
m.troubat@azergo.fr
jl.muller@azergo.fr
v.blin@azergo.fr
+ Add Recipient
The report will be sent to these additional addresses
I confirm sending this report to the recipients above
Please confirm before sending.
Submit Report
Verify that all photos and documents are attached before sending.
