Claim form

Non Fault Driver Claim Form
Claiming:*

Personal InjuryVehicle DamageLoss of earningsHire, Recovery, Storage
Client Name*

TitleFirst NameLast Name
Date of birth*
National Insurance Number*
Job
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number

Area CodePhone Number
Vehicle & Insurance Details:
Client Vehicle Reg*
Make & Model
Insurance Company
Cover
Policy No
If you are not owner of this vehicle, please provide owner details?
Accident Details:
Accident Date*

MonthDayYear
Time*

:HourMinutesAM/PM Option
Accident Location:*
Road Name, Postcode.
Road Condition?
Weather Condition?
Please specify the damage caused to you vehicle:
Brief description of the incident:*
Select

Hire RequiredVehicle RecoveredRoadworthyVehicle in storage
Have you suffered any injuries from the collision: YES / NO If yes please specify?

Shock / Shaken UpWhiplashBruisingBang to HeadCuts / Grazes
Have you attended the GP / Hospital as a result of the collision: YES / NO. If yes where and when
GP Details: *
Passengers, Witness & Police Details:
Number of passengers in the vehicle at the time of the accident (Including driver):
Name, Contact No: if more than 1 passenger please write Name & contact no:
Police Ref/Cad No:
Witness Details

First NameLast Name
Phone Number

Area CodePhone Number
Address, e-mail.
Other Information
Fault Party Details:
Third Party Name

First NameLast Name
Address:
Phone Number

Area CodePhone Number
TP Vehicle Reg:*
Make & Model & Color:
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Declaration:

I hereby appoint First Car to act on my behalf and authorise a solicitor of choice to pursue my claim. I confirm that all of the information provided is true and to the best of my knowledge. I am also aware that if I claim for personal injury that the solicitor will charge a %TBA fee of my personal injury.
I authorise First Car to arrange engineer inspection, repair my vehicle of the agreed engineers value or payment amount received from third party in respect of vehicle damage, If my vehicle is deemed unroadworthy I authorise First Car to arrange credit hire and credit storage and Credit Recovery if applicable.
Signature
For office use only

PassportDriving licence cardInsuranceV5 (Logbook)MOTTaxi licenceVehicle Taxi licence
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PCO Paper:

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