Motor Claim Form

SECTION 1 - DETAILS RELATING TO THE INSURED AND INSURANCE COVER
1.1 Title
1.2 Full Name of Insured
1.3 Address


1.4 Postcode
1.5 Telephone Number (Home)
1.6 Telephone Number (Work)
1.7 Full Time Occupation
1.8 Part Time Occupation
1.9 Policy Number
1.10 Cover
1.11 Claim Number
1.12 Broker
1.13 Are you VAT Registered YesNo
1.14 If "Yes", please state what percentage VAT registered you are %

SECTION 2 - DETAILS OF ACCIDENT, FIRE OR THEFT
2.1 Date
2.2 Time
2.3 Place
2.4 Town
2.5 County
2.6 Weather conditions
2.7 Date reported to Insured
2.8 Reason for journey
2.9 Did a Police Officer attend YesNo
2.10 Police Station
2.11 PC's Number
2.12 Was anyone cautioned or breathalysed YesNo
2.13 Who
2.14 Result
2.15 Police Crime Reference Number
THEFT Please note it usually takes 4 to 6 weeks to investigate a theft claim
2.16 Is the thief known to you YesNo
2.17 Was the vehicle locked YesNo
2.18 Were the keys removed YesNo
2.19 How many keys were you given when you purchased the vehicle
2.20 Was an alarm or immobiliser fitted YesNo
2.21 Was it engaged YesNo
2.22 Make/Model

SECTION 3 - DETAILS OF DRIVER OR PERSON LAST IN CHARGE OF THE INSURED VEHICLE
3.1 Title
3.2 Name
3.3 Address


3.4 Postcode
3.5 Date of Birth
3.6 Date HGV/PSV Test Passed
3.7 Groups
3.8 Date UK Test Passed
3.9 Expiry Date
3.10 Occupation
3.11 Licence
3.12 Country of Issue
3.13 Length of UK Residency
3.14 Please give details of any medical condition affecting you.  If none, please state "NONE"
3.15 Please given details of any motoring conviction or pending prosecution.  If none, please state "NONE"
3.16 Please give details of any previous losses. If none, please state "NONE"
3.17 Was the driver engaged on your business YesNo
3.18 Is the driver in your employ YesNo
3.19 Date employed commenced

SECTION 4 - VEHICLE DETAILS
4.1 Make
4.2 Model
4.3 Registration Number
4.4 Year of Make
4.5 Date Purchased, Hired or Leased
4.6 Purchase Price
4.7 Estimated Present Value
4.8 Type of Vehicle
4.9 Engine Size
4.10 Mileage
4.11 Date last MOT passed
4.12 Was a Trailer/Caravan attached YesNo
4.13 Length of Trailer/Caravan
4.14 Name and Address of HP/Lease Company
4.15 HP/Lease Agreement Number
4.16 Was the vehicle being used with your permission YesNo
COMMERCIAL VEHICLES ONLY
4.17 Gross vehicle weight
4.18 Length of vehicle
4.19 Type of load
4.20 Do you hold an Operators Licence YesNo
4.21 Licence Number
4.22 Expiry Date
PLEASE GIVE OWNERSHIP DETAILS IF YOU WERE DRIVING A VEHICLE THAT IS NOT OWNED BY YOU
4.23 Title
4.24 Name
4.25 Address


4.26 Postcode
4.27 His/Her Insurance Company
4.28 Policy Number

SECTION 5 - DAMAGE TO OWN VEHICLE
If the vehicle is damaged beyond economic repair we will move it to safe storage pending settlement of you claim. Please remove your personal effects as soon as possible.
5.1 Degree of Damage
5.2 Is the vehicle still in use YesNo
5.3 Is the vehicle unable to be driven YesNo
5.4 Has the vehicle been recovered YesNo
5.5 Area of Damage (give particulars of damage to your vehicle)
5.6 Where can your vehicle be inspected
Theft: If the vehicle has been recovered
5.7 Who recovered the vehicle
5.8 Where was it found
5.9 When was it found
5.10 Where has it been taken
DETAILS OF OTHER VEHICLE OR PROPERTY INVOLVED
5.11 Title
5.12 Name
5.13 Address


5.14 Postcode
5.15 Make
5.16 Model
5.17 Colour
5.18 Was their vehicle driven away YesNo
5.19 Damage
5.20 Insurers
5.21 Policy Number
5.22 Vehicle Registration

SECTION 6 - FULL DESCRIPTION OF ACCIDENT OR THEFT
6.1 Please give a full description of the Accident, Fire or Theft
6.2 Speed of your vehicle at time of accident
6.3 Speed of other vehicle at time of accident

SECTION 7 - LIABILITY
7.1 Who in your opinion was to blame
7.2 Are you pursuing a claim for uninsured losses YesNo
7.3 In the event of Civil Litigation do we and our Solicitors have your permission to admit liability and negligence YesNo

SECTION 8 - WITNESS OF ACCIDENT
8.1 Title
8.2 Name
8.3 Address


8.4 Postcode
8.5 Status

SECTION 9 - PERSONS INJURED
9.1 Title
9.2 Name
9.3 Address


9.4 Postcode
9.5 Status
9.6 Nature of Injury
9.7 Seat belt used YesNo
9.8 Hospitalised YesNo

SECTION 10 - PASSENGERS
10.1 Number of Passengers in your vehicle
10.2 Number of Passengers in other vehicle
     

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I/We declare that to the best of my/our knowledge and belief all the foregoing particulars are true and correct in all respects and request you deal on my/our behalf with any claims which may arise out of the incident in accordance with the terms and conditions of the insurance.