Incident Description

Date of Incident

Time of Incident

Your Vehicle Reg.

Policy Ref/Certificate Number:

Please briefly describe the incident:


Policy Holder Details

Insured Name:

Insured Address:

Contact Telephone:

Contact Email:

Are you VAT Registered:YesNo




Vehicle Details

Make: Model: Registration Year:

Any Modifications to Vehicle:YesNo

Please provide details:

Who is the Owner:

Who is the registered keeper:

Who is the main user of the vehicle:

For what purpose was the vehicle being used at the time of the incident:

Was a trailer being towed:YesNo

Please provide details:

Was any goods being carried:YesNo

Please provide details:

Is the vehicle subject to:Hire PurchaseLeasing AgreementNeither

Please provide further information:


Driver Details

Name:

Date of Birth:

Driver Address:

Occupation:

Is the Drivers License:Full UK LicenseProvisional LicenseEU LicenseInternationalOther

Please provide details:

Number of Years license held:

If HGV/PCV License please state License Class:

Was the vehicle being used with the insured's consent:YesNo

Does the driver have any disability we have not been told about:YesNo

Please Provide details:

Does the driver have any convictions or impending prosecutions for motoring offences:YesNo

Please provide details (if any of these convictions were the result of a penalty notice or include a period of disqualification please include the details):

Please provide a summary of convictions information:

Offence Code Conviction Date Penalty Points Fine Category

*If more than three convictions please supply this information in email to our Claims team for inclusion in this claim.





Accident Information

Accident Location:

Weather conditions at time of incident:

Road conditions at time of incident:

Speed prior to incident:

Speed at impact:

Do you believe the driver was at fault for the incident, if not why:

Were there passengers in the vehicle:YesNo

Please provide information if passengers were injured:





In Cases of Theft

Loss Location:

If recovered, when and how did this happen:


Cases of Damage

Please describe the damage to your vehicle:

Is the vehicle immobile:YesNo

Please advise details and the location of the vehicle:

Do you wish to claim for your damage:YesNo

Are you happy for us to appoint a garage on your behalf:YesNo

Please provide us with your garage details, a full estimate and images of the damage:

(please note, this could effect the possibility of being provided with a courtesy vehicle)


Third Party Details

Name, Address & Contact Details:

Vehicle Make, Model & Registration number:

Were there passengers in the vehicle:YesNo

Please provide name and contact information:

Was there any damage to Third Party property (excluding vehicle, i.e. premises, pillars, fences, etc.):

Were there injuries to any of the parties involved:YesNo

If Yes, please provide details including name of hospital if known:


Claims Involving Police or Witnesses

Were the police present at the scene:YesNo

Please provide details including the police station address & reference number:

Were there any witnesses present at the scene:YesNo

Please provide details including the name, address and telephone number:





Evidence

Do you wish to include a sketch for us:YesNo

Before the incident After the Incident



Declaration

I have read and checked this proposal for completeness and accuracy. To the best of my knowledge and belief, I confirm that the information given, whether in my own hand or not is complete and accurate.

I understand that this proposal does not bind the Proposer to complete the insurance but, if accepted, this proposal will form the basis of the contract between the Proposer and the Underwriters.

I understand that any material misrepresentation or non-disclosure may lead to avoidance of the insurance by the Underwriters. I understand that any information provided to the Underwriters regarding the Proposer will be processed by the Underwriters, in compliance with the provisions of the Data Protection Act 1988, for the purpose of providing insurance and handling claims which may necessitate providing such information to third parties.

Driver Signature:

Date:

Insured Signature:

Date: