Road Traffic Accident Claim Form

Your Motor Insurance Details

Only complete this if you were driving a vehicle when the accident and injury occured.
Vehicle owner's full name:

First NameLast Name
Vehicle driver's full name:

First NameLast Name
Name of Insurance company
Insurance Policy Number:
Type of Insurance cover:

Third PartyThird Party, Fire and TheftFully Comprehensive

Details of Third Party's Motor Insurance

The Third Party is the driver who caused the accident and your injuries
Name of driver

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The name of their Insurance company
Policy number:
Vehicle make, model and registration number (and owner if known to be different from the driver) of the vehicle:

Physical Injuries + Medical Details
What injuries did you suffer from the accident? Please tick all that apply

Soft tissueBoneWhiplashOther
Please describe the injuries you had suffered: (e.g. neck pain, back pain, broken bones, etc) and whether you have recovered from them:
Do you have any pre-existing health or medical issues that were made worse by the accident? (e.g. pre-existing back pain or neck pain)
Did you bang your head?

YesNoNot sure
If yes, please give a brief description including whether you lost consciousness and what you banged your head on.
Have you been dizzy at all or fainted?
Have you felt any nausea or sickness?
Any sensation of 'pins and needles' or pricking sensation in limbs, numbness or loss of sensation?
If so, where?
Can you remember all the events leading up to the accident?
Can you remember the accident itself clearly?
Can you remember all the events after the accident?

Psychological Injuries

Please complete this section if you feel that you suffered shock and/or psychological trauma.
Did you suffer shock in this accident?
If yes, are you fully recovered?
If you have recovered, on what date did this happen?

DayMonthYear
If you continue to be psychologically affected by the accident, please provide details of your symptoms below (e.g. flashbacks, disturbed sleep, low mood, etc).
Do you have any pre-existing psychological issues that were made worse because of the accident?
Please upload photographs of injuries and any hospital appointment letters:

Cancelof

General Practitioner / Minor Injuries Unit/ Hospital visits for injury treatment
Have you sought medical attention/advice?
If yes, on what date did you first do so?

DayMonthYear
Did you attend at a hospital as a result of the accident?
If yes, please provide the name and location of the Hospital(s) attended:
Were you kept in overnight in hospital?
If yes, how many days were you kept in hospital?
Have you seen your own Doctor?
If yes, please give the name and address of your Doctor and the dates you were seen:
Has a medical expert recommended rehabilitation treatment? (e.g. physiotherapy, talking therapies, etc)
If yes, please provide details of the rehabilitation treatment provider:

Financial Losses and Loss of Earnings
Did you suffer any loss of wages or salary?
If yes, how much?
How long were you off work?
You were absent from work from:

DayMonthYear
Date
You returned on:

DayMonthYear
Date
Your employer's name:
Your employer's address:
Did you receive Statutory Sick Pay?
Did you claim SDD Sickness Benefit or Universal Credit?
Did you have any vehicle related financial losses? (e.g. Policy excess), was your vehicle written off? Did you enter into a Credit Hire Agreement for a hire car?
Did you suffer any other financial losses? If so please provide details here
Please keep your receipts for any financial losses suffered as a result of your accident safe. These could be expenses such as parking for hospital / rehabilitation treatment appointments, prescription fees, medication expenses, damaged item expenses, etc.
How did you hear about Thatcher + Hallam?*
Should be Empty:

Your details