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Claim Form

This document provides a guide for recording information about an incident in order to make an insurance claim. It includes sections to record details of the incident such as date, time, location, whether police attended. It also includes sections to record information about passengers, other vehicles involved, drivers' details and any injuries. The guide stresses the importance of recording as much information as possible and calling the claims team within 48 hours of any incident.

Uploaded by

Jim Nasco
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
215 views1 page

Claim Form

This document provides a guide for recording information about an incident in order to make an insurance claim. It includes sections to record details of the incident such as date, time, location, whether police attended. It also includes sections to record information about passengers, other vehicles involved, drivers' details and any injuries. The guide stresses the importance of recording as much information as possible and calling the claims team within 48 hours of any incident.

Uploaded by

Jim Nasco
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Incident

Incident details Independent witnesses


Date: Location: Name: Tel No.:

information
Time: Did the Police attend?: Y/N Address:
Name/station of officer:
Reference:
Name: Tel No.:
This guide is designed to help you make a claim
if you are involved in an incident. You do not Address:
need to send it to us, simply use it to record Passengers in your vehicle
as much as possible before calling the Claims Passenger name: Injured? Treated? Nature of Injury
Team with the information.
Name: Tel No.:

1
1.

Stop...
2. Address:
3.

4.

when it is safe to do so, whether


or not the accident was your fault.

2
Other vehicle involved: 1 Other vehicle involved: 2

Check... if anyone has been hurt and call the


Make:
Reg No:
Area of damage:
Model:
Was the vehicle driveable? Y/N
Make:
Reg No:
Area of damage:
Model:
Was the vehicle driveable? Y/N

emergency services on 999 if necessary. Driver name: Driver name:

3 Note...
Driver address: Driver address:

Driver telephone: Driver telephone:


as much information as you can, Insurer: Insurer:
use this form below as a guide.

4
Policy Number: Policy Number:

Call...
No of passengers in vehicle: No of passengers in vehicle:
Passenger name: Injured? Treated? Nature of Injury Passenger name: Injured? Treated? Nature of Injury
1. 1.
the Claims Team on 0800 840 2103.
They are available 24 hours a day. 2. 2.

3. 3.

4. 4.

Photos Driver: Driver:


If possible, take photos of the incident showing
5. 5.
positions and registration numbers of the vehicles
involved, road layout and marks in the road, and
any vehicle damage. If more than 2 other vehicles are involved in the incident then please note down details on the back of this sheet.

Don’t delay, call today: 0800 840 2103


Let us know about any incident as soon as possible (within 48 hours) whether you are intending to claim or not.
Delays could affect the way that the claim is dealt with and could also result in additional costs being incurred.

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