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Accident Claim Form

Complete all sections accurately. Issue of this form is not an admission of liability.

Policy Information

Policy NoGroup Scheme / Fleet Name

1. The Insured

Identity NoFull Name*

Address

Postal CodePhone (Business)Phone (Home)Email

2. The Vehicle

Make & Model*Registration Number*Year

3. Driver at Time of Accident

Full NameIdentity NoPhone (Business)Phone (Home)Occupation

4. Accident Details

Date of Accident*

Location*

Description of how the accident occurred*

Injury Severity

Vehicle drivable after accidentTow truck required

Police Reference / CAS NumberPolice Station

5. Third Party

Third party involved in accident

6. Declaration

I declare that to the best of my knowledge and belief the foregoing particulars are true, correct and a complete disclosure of the circumstances relating to the claim, and I undertake to render to the company every assistance in my power in dealing with the matter. I also declare that there is no other insurance under which a claim can be made and that the said vehicle is my sole property.

Date*

I agree to the above declaration

Issue of this form is not an admission of liability