Motor Claims Form
Policyholder Details
Policyholder Name
*
Policyholder Address
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Policyholder Telephone No.
*
Are you VAT Registered?
*
Yes
No
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Driver Details
Driver name
*
Driver address
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Driver telephone No.
*
Front of drivers licence
*
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Please upload a copy of the front of the Drivers Licence
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Back of drivers licence
*
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Please upload a copy of the back of the Drivers Licence
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Has the driver been concerned in any accident or lossduring past five years?
*
Yes
No
Has the driver ever been declined or refused renewal for vehicle insurance?
*
Yes
No
Has the driver got any physical defect, infirmity or impairment ofsight or hearing?
*
Yes
No
Has the driver been prosecuted or incurred a Fixed Penalty for an endorseable offence in connection with a motor vehicle during the last five years, or have any prosecution(s) pending?
*
Yes
No
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Vehicle Details
Vehicle reg
*
Vehicle make
*
Vehicle model
*
Year of manufacture
*
Vehicle Mileage
Who is the registered owner?
*
Is the vehicle driveable?
*
Yes
No
Do you wish to use an approved repairer
*
Yes
No
Which area of the UK?
*
Do you wish to use your own repairer
*
Yes
No
Please provide details of the repairer
*
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Accident Details
Accident date
*
-
Day
-
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Accident Location
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Accident Description
*
Accident sketch
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Please upload a sketch of the accident
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Do you accept liability?
*
Yes
No
50/50
Did the police attend the scence
*
Yes
No
Please provide name,number and station address
Were there any witnesses?
*
Yes
No
Please provide name & contact number
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Third Party Details
Third Party Driver
First Name
Last Name
Third Party Telephone No.
Third Party Vehicle Reg
Third Party Insurers
Name of Third Party Insurance Company
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