Motor Claim Form

Policy Number
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First Name
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Surname
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Address
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Postcode

Phone

Email Address
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Occupation
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VAT Registered
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Type of Vehicle
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Make and Model
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Vehicle CC
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Year of Manufacture
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Registration Number
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Mileage
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Colour
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Is the vehicle owned, leased or loaned? If yes, please give details.
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No of passengers including driver?
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Any injuries to driver or passengers?
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First Name
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Surname
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Address
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Postcode
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Date of Birth
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Is the driver employed by you?
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Was the driver authorised?
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Purpose of Journey?
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Any convictions for motoring offences? If so please state details and dates.
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Any charges pending?
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What occupation is the driver in?
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Type of Licence
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Years Held
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Age of Driver
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Date of Accident
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Time of Accident
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Location
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Description of Road
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Weather Conditions
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Speed Limit
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Speed of your vehicle before impact?
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Speed of your vehicle at the moment of impact?
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What lights were showing?
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Was any warning given?
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What was the vehicle being used for?
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Description of Damage
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Approximate Cost of Repair
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Please attach estimate where applicable
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Where can it be inspected?
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Is the vehicle still in use?
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Do you want to use an Insurer Approved Repairer?
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First Name
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Surname
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Address
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Postcode
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Phone
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Registration Number
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Make and Model
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Insurers Name
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Insurers Address
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Policy/Certificate Number
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Apparent Damage
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No of Passengers Including Driver?
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Any Injuries to Driver or Passengers?
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Property Damaged/Injured Persons (If passengers, please state in which vehicle)
First Name
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Surname
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Address
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Postcode
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Description of Property
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Extent of Damage
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Injured Persons
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State name and address (whether driver, pedestrian) details of injury, medical attention needed, name of hospital etc.

Witness 1 - Name
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Witness 1 - Address
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Witness 1 - Phone
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Witness 2- Name
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Witness 2 - Address
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Witness 2 - Phone
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Witness 3 - Name
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Witness 3 - Address
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Witness 3 - Phone
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Were the police informed?
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Did they attend?
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Are proceedings pending? If so against whom?
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Name and Number of Officer
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Station Address
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Additional information
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(Please provide a description of the accident circumstances)

Please attach any further information (including diagrams)
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