Uninsured Loss Recovery Services | 24 Hour Helpline: 0800 298 0455

Date of Enquiry*

Claim Referred by*

Client Address*

Date & Time of Incident*

Client Name*

Driver at Time of Incident*

Driver Address (if different from above)

Use of Vehicle at Time of Incident*

Driver Date of Birth*

Drive's Home Number*

Driver's Mobile Number

Driver's Occupation*

Drive's Work Number

Driver's Convictions (If any)

Driver's Disabilities (If any)

Has the driver been involved in any previous accidents*

Yes

No

Any modifications to client's vehicle

Is client registered for VAT purposes

How long has client held a full UK Driving Licence for*

Broker*

Broker Contact*

Policy Number*

Motor Renewal Date*

Insurer*

Branch Address

Branch Phone Number

Insurance Cover*

Third Party

Third Party Fire & Theft

Fully Comprehensive

Claims Reference Number*

Excess (in £)*

Any Legal Expenses

Legal Policy Number

Personal Injury*

Yes

No

Solicitor

Is Vehicle Driveable*

Yes

No

Location of Vehicle*

Is Vehicle Booked in for Repairs*

Yes

No

Name of Vehicle Repairers

If Yes please give date booked in for

Vehicle Damage Total Loss (in £s)

Vehicle Registration*

Vehicle CC*

Vehicle Type: Check where appropriate

Choice 1

Choice 2

Choice 3

Vehicle Make*

Model*

Colour of Vehicle*

Weather Conditions*

Speed of Client's Vehicle at time of Incident*

Incident Location*

Circumstances of incident*

Witnesses

Were the Police called*

Yes

No

Name of Station (if known)

Name of PC (if known)

Reference Number (if known)

What details where exchanged at the scene

Third Party Driver Name*

Company Name (If applicable)

Company Address (if applicable)

Driver's Address*

Driver's Phone Number*

Make, Model and Colour of Third Party Vehicle

Vehicle Registration

Damage to Third Party Vehicle*

Third Party Insurance Company Name and Address

Third Party Insurance Company Phone Number

Insurance Policy Number

Claim Reference

Any further information to add

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Online Motor Claim Form

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