Insurance Claims Reporting Form (OLD)

Insurance Claims Reporting Form
Has a fatality occurred?*
In the event of a fatal accident, please contact Clyde & Co Solicitors on 07972 999 999

They will require confirmation of your insurance details which are:

Allianz Insurance Plc

Policy Number: 55/BV/29230123/10

**Please ensure Clyde & Co are contacted before speaking to anyone including: Attis Insurance Brokers,

Police and your Line Manager, no matter how straightforward the circumstances may be.**

Clyde & Co are there to protect you, as a driver.

Clyde & Co will take over conduct of the claim with the police.
Was a Third Party involved*
Third Party Details
Third Party Driver Name
Third Party Driver Vehicle Registration
Third Party Driver Phone Number
Third Party Driver Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In your opinion who caused the incident?*
Photos of Incident*

Take Photo
Please take photos of the incident BEFORE moving the vehicle so we can see what happened, if it was a theft please show any break in damage Cancelof
Photos of Damage to 3rd Party Vehicle*

Take Photo

Cancelof

Incident Details
Your Vehicle Registration*
The registration of the vehicle YOU were driving at the time of the incident
Mileage*
Mileage of your vehicle.
Circumstances of Incident*
Please describe what happened, the more detail the better
Date & Time of Incident*

DayMonthYear
DateHourMinutes
Location of Incident*
e.g. 'Just before junction 62 of the A1, Northbound', or 'on the A19 flyover in Stockton'
Is your MAP vehicle still driveable?*
Was anything stolen?*
Is there any Damage to Company Vehicle?*
Photos of Damage to Company Vehicle*

Take Photo

Cancelof
If the vehicle is not driveable / written off, please contact Allianz Insurance Plc directly on 0370 606 4912 (option 2 to report a new claim). Allianz will take the claim details and appoint their recovery agents.

You will be asked for the following information:

Company Name: Map Group (UK) Ltd

Policy Number: 55/BV/29230123/10

Driver Details
Your Full Name*
Your Team Leader*
Your Location / Department*
Your Phone Number*
This is so the garage can contact you to arrange collection for repair or so we can contact you if we need further information
Your Date of Birth*

DayMonthYear
Driver Pass Date*

DayMonthYear
The date you passed your driving test (don't worry if you can't remember the exact date, just the month and year will be fine e.g. 01-05-2007)
Driving Convictions*
Please type any driving convictions you have had in the last 5 years including the date e.g. IN14 - Dec 2016. If you have no driving convictions please type 'None'
Medical Conditions*
Please type any DVLA reportable medical conditions you have, if you have no DVLA reportable medical conditions please type 'None'
Should be Empty:

Insurance Claims Reporting Form