Motor Claim Form

Please fill out all the fields below where applicable, providing as much detail as possible. This will help us to speed up the process of your Claim Form.

Policy Holder Details

Name of Company:
Email:
Address Line 1:
Address Line 2:
Town/City:
County:
Post Code:
Telephone Number:
VAT Registered?

Driver Details

Name of driver:
Address Line 1:
Town/City:
County:
Post Code:
Date of Birth:	- -
Occupation:
Class of Licence
Date Test Passed	- -
Details of any convictions
Details of any disabilities
How long employed by the company
Purpose of the Journey

Vehicle Details

Make & Model
Registration Number
Year of Manufacture
Vehicle Modifications
In Company Name
Number of passengers
Is the vehicle leased

Damage to Insured Vehicle

Details of damage
Still in Use
Location

Details of Theft/Attempted Theft

Vehicle Left Unattended
Ignition key removed?
Locked with a security device
Reported to the police?
If yes provide details of Police Station, Officer & crime reference number

Details of Incident

Date & Time of Incident	- - :
Location
Reported to the police?
If yes provide details of Police Station, Officer & crime reference number
Please give a full description of the incident. This should include the speed of the vehicles and weather conditions at the time.
Whom do you consider responsible?

Third Party Details

Name and full address of third party driver and/owner of vehicle
Make & Model
Registration Number
Details of any damage to the vehicle
Insurers' name & Policy number
Number of passengers
Other Injured persons details
Details of injuries sustained
Were seatbelts worn?

Witnesses

Names & Addresses
If a passenger, which vehicle?
Form Completed by
Date	17th May 2012