Making a Claim

 

Section 1 - Policy Holder Details

 

 

 

 

 

 

 

 

 

 

 

 


Section 2 - Driver Details

 

 

 

 

 

 

 

 

 

 

 

Section 3 - Vehicle Details

 

 

 

 

 

 

 

 

 

 

 

 



Section 4 - Vehicle Damage

 

 

 

 

 

 

 

 

 

 

Section 5 - Accident Details

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 6 - Other Persons Involved

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 7 - Witness Details

 

 

 

 

 

 

 

 

 

Section 9 - Injuries

 

Motor Insurance Claim

 


Title

  

Full Names

 

Surname

 
   

Postal Address

 

Town / City

 

County

 

Post Code

 
   

Telephone Number

 

Fax

 

Occupational / Business

 

Are you VAT Registered?

 

If you are partially exempt please state % recoverable

  

%

 

    

 

    

Driver First Name

 

Driver Surname

 

Telephone Number

  

Occupation

  

Date of Birth

  

Type of License

 

Date Licence Issued

  

Does driver have any points on licence or convictions?

  

If YES, please specify

 

 

    

 

    

Vehicle Details

 

Model

  

Reg Number

 

Colour

  

Mileage

  

Date of Registration

 

Who is the legal owner?

 

How long have you owned the vehicle?

 

Has the vehicle been modified?

 

Name of hire purchase / lease company (if applicable)

 

Address

  
     
     

What is the damage to your vehicle

 

Do you wish to use an approved repairer?

 

If you do not wish to use an approved repairer, please supply repair estimate

Repairers name and address & telephone number

 

Is your vehicle at the repairer?

 

If vehicle is damaged beyond repair, it may be moved to free and safe storage
     
     

Date

  

Time

  

Your speed

  

Location of accident

  

Road / weather conditions

  

Were the police involved?

  

If yes, please confirm station
details and reference

  

Were there any passengers?

  

Please give a full description of the accident (add additional sheets if required)

  

Do you feel responsible for the accident?

  

     
     

Third party name, address
& telephone number

  

Third Party Insurance
Details

  

Vehicle make

  

Vehicle model

  

Registration

  

Colour

  

Damage to other vehicle

  

Were there any passengers?

  

     
     

Were there any witnesses?

    

Name, address & telephone number

  

Is the witness independent?

  

Name, address & telephone number

  

Is the witness independent?

  

     
     

Was anyone injured?

  

Name, address & telephone number

  

Nature of injuries

  
     

Name, address & telephone number

  

Nature of injuries