Claim Form

Claim reference
Time & date of incident
Name of policy holder
Incident location, including road
name and junctions

Who was driving the vehicle or

had last been in control of the
vehicle?
Please confirm how many
vehicles in total were involved in
the incident
Please confirm how many
occupants in each vehicle
(including driver) and state any
injuries

Did police attend the scene and

are they investigating?
Police station and case
reference.
Is CCTV available? Please
provide details for how we can
obtain this.

Please provide the details of any witnesses

Are the witnesses known to you or the third

party? If so please confirm how
Third party vehicle registration(s)

Describe the make, model & colour of the

third party vehicle(s)
Please describe what happened (if you
require more space please use a separate
sheet)

If there were multiple vehicles involved

please confirm the order and how many
impacts you felt

Please confirm who you believe was at fault

for the incident

Please sketch the position of the vehicles, any road markings and road sign’s below. Please also show
on this sketch your own position.

Please provide details of the

damage to your vehicle,
including location and
severity
Please provide details of the
2 of 3
damaged to any third party
vehicle(s)
Will you be making a claim
for personal injury; if so, do
you have a solicitor?
Will you be willing to attend
court, should the third party
or their insurer fail to settle
the claim?

Print Name: ……………………………………………………………..

Signature: ……………………………………………………………….

Date: ……………………………………………………………………

3 of 3