Motor Vehicle Accident Notification Form

This form must be used to report any motor vehicle accidents that occur on NT Airports property or involve NT Airports staff or contractors.

Part 1 – Reported By

First & last name *

Phone number *

Email address *

Mobile number *

Place of employment *

Occupation *

Your supervisor's email *

Part 2 – Incident Location

Airport *

Darwin International Alice SpringsTennant Creek

Description of location *

Incident date and time *

Part 3 - Incident Summary

Describe what happened *

Detail any injuries

Were the Police informed? *

YesNo

PROMIS No. *

Sketch the incident

Clear drawing

(OR upload a photo of the sketch below)

Upload a photo of the sketch

Browse

(If not drawn above)

Part 4 - Incident Conditions

Road type *

SealedUnsealed

Road quality *

Very goodGoodAveragePoor

Visibility *

Very goodGoodAveragePoor

Part 5A - Vehicle 1 Details

Driver 1 Details

First & last name *

Phone number *

Email address *

Mobile number *

Date of birth *

Gender *

MaleFemaleOther

Driver's licence number *

Expiry date *

Class of licence *

State *

Vehicle 1 Details

Vehicle make/ model *

Registration number *

Expiry Date *

Vehicle type *

Describe the damage to the vehicle *

Is the vehicle driveable? *

YesNo

Passenger Details (Vehicle 1)

List the details of any passengers in the vehicle at the time of the incident:

Passenger 1 full name

Phone number

Passenger 2 full name

Phone number

Passenger 3 full name

Phone number

Passenger 4 full name

Phone number

Part 5B – Vehicle 2 Details (if applicable)

Driver 2 Details

First and last name

Phone number

Email address

Mobile number

Date of birth

Gender

Male Female Other

Drivers Licence number

Expiry date

Class of licence

State

Vehicle 2 Details

Vehicle make/model

Registration number

Expiry date

Vehicle type

Describe the damage to the vehicle

Is the vehicle driveable?

YesNo

Passenger Details (Vehicle 2)

List the details of any passengers in the vehicle at the time of the incident:

Passenger 1 full name

Phone number

Passenger 2 full name

Phone number

Passenger 3 full name

Phone number

Passenger 4 full name

Phone number

Part 6 – Declaration

I declare the information provided in this form is a true account of the incident. I acknowledge that NT Airports may need to disclose details of this report, including personal details, to relevant third parties. *

Signature of person listed in Part 1 *

Draw signature|Type signatureClear

Date

Investigation Assignment

Investigation assigned to:

Name *

Email *

Title *

Phone number *

CAPTCHA *

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