ROAD ACCIDENT CLAIM FORM

Full Name (required)

Email address (required)

Address

Postcode

Occupation

Date of Birth

Address

Postcode

Section 2: Accident Details

Accident Date

Accident Time

Please select the appropriate box to indicate which applies to you
DriverPassengerPedestrianCyclistMotorcyclist

How many people were in your vehicle (including you)?

Where were you seated?

Were you wearing a seatbelt?

Where did the accident happen?

Weather conditionsSunRainSnowFogIce

Road conditionsDryWet SnowIceMudOil

Section 3: Third Party Details

Registration

Make

Model

Colour

Third Party’s Name

Telephone Number

Address

Postcode

Third Party Insurer’s Name

Third Party Policy Number

Approximate age of other party?

Was the other party male or female?

Description of the other party

How were the other party’s details obtained?

Section 4: Your Vehicle Details

Registration

Make

Model

Colour

Policy No

Reference No

Cover

Policy Excess

Insurance Company Name

Telephone Number

Insurance Company Address

Postcode

Is your vehicle driveable?YesNo

Is your vehicle likely to be total loss?YesNo

If repairable, what is the repair position?CompleteAuthorisedNot yet authorizedNot known

Is your insurer dealing with the vehicle damage claim?YesNo

Is an alternative company dealing with the repairs?YesNo

Section 5: Witness Details

Witness 1 Name and Address

Witness 1 Telephone Number

Witness 2 Name and Address

Witness 2 Telephone Number

Section 6: Injuries

Type of injury sufferedSoft tissueBone injuryWhiplashOther

Describe your current symptoms

Section 7: Treatment

Did you seek medical attention?YesNo

If YES, when?

Were you detained overnight?YesNo

If so, how many nights?

Did you attend hospital?YesNo

Section 8: Police Details

Was the accident reported to the police?YesNo

Police Station Name and Address

Name of Officer

Reference Number

Telephone Number

Section 9: Statement of truth