STATEMENT OF TRUTH

Our Reference: KAM/TB1/197222

*PLEASE COMPLETE IN CAPITALS AN BLACK INK* 1! C"#$%#n& 'e&#$"( Your Full Name: Your Full Address:

Occupation: D.O.B: 2! e&#$"( )f &*e 'r$+er ,)u -e"$e+e $( &) -"#%e f)r &*e #cc$'en&. Name: Address:

Telephone: Description of Driver: How did you o tain these details!

/! 0e*$c"e -e$n1 'r$+en -, &*e 2er()n ,)u -e"$e+e $( &) -"#%e f)r &*e #cc$'en&. "e#istration Num er: $a%e: $odel: &olour: 'assen#ers in (ehicle: Please indicate number of.

3! Acc$'en& c$rcu%(&#nce( Date of )ncident: Time of )ncident: *+act ,ocation of )ncident:

4! In'e2en'en& 5$&ne((e( Y*-.NO

(not known to you prior to the accident)

Names // Addresses of any witnesses: Please note they must be independent and must have seen the incident occur

6! P)"$ce In+)"+e%en& Y*-.NO 'olice Details: Please include Officer Name/No, Incident No

Our Reference: KAM/TB1/197222

7! e(cr$2&$)n )f Inc$'en&

7! Are# )f #%#1e )n ,)ur 0e*$c"e

9! S8e&c* )f Inc$'en& Please provide a detailed sketch of the incident (showing e act locations of all vehicles involved leading upto the incident and following the incident! I" #O$ %&'( &N# PI)*$+(, O" *%( ,)(N( P-(&,( (N)-O,( O+ (.&I- *O $, claims/kindertons.co.uk (please include your claims ref number!

)01111111111111111.2Name of &laimant30 elieve that the facts stated in this description are a true and accurate statement of events. -i#nature:1111111111111111Full Name:11111111111.Date:11111111