Motor Accident Report Claim Form 2025

Motor Accident Report Claim Form

IMPORTANT

We wish to process your claim as quickly as possible. Therefore, please ensure:

• All questions are fully answered.
• All required documents are attached.
• Return completed form to us within 24 hours.

Failure to do so will delay the claim. If in doubt please contact us.

GUIDANCE NOTES

Most delays in settling claims arise because claim forms are not fully completed or requested documents are not sent to us. We would therefore ask you to answer all questions (dashes and spaces cannot be accepted).

You should read and sign the declaration.

If you are unable to supply any of the requested documents, please include a separate note explaining why this is, to enable us to help you more quickly.

PLEASE READ CAREFULLY AND PLEASE ANSWER ALL QUESTIONS IN FULL.

POLICYHOLDER’S DETAILS (STEP 1 / 8)

To be completed by the claimant - all fields are required.

Full Name / Company Name:

Date of birth:
(If not a company)

Address:

Postcode:

Telephone number:

Mobile number:

Business telephone number:

Email address:
(Claim form confirmation will be sent to this email address)

Occupation / Business:

Are you registered for VAT?

VAT status?

VAT number (if applicable):

DETAILS OF DRIVER (OR LAST PERSON TO DRIVE BEFORE INCIDENT) (STEP 2 / 8)

Full Name:

Date of birth:

Address:

Postcode:

Home telephone number:

Mobile number:

Business telephone number:

Email address:

Full time occupation:

Part time occupation:

Driving licence number:

Date test passed:

Licence expiry date:

Type of licence?

If you have selected 'Other' above, please describe your type of licence, and nationality:

Was the vehicle being used with Policyholder’s consent?

If not the Policyholder driving, does the driver have his own insurance?

If you have selected 'Yes' above, give details of insurers:

Relationship of driver to Policyholder if other than Self?

If you have selected 'Other' above, please specify:

CONVICTIONS, OTHER CLAIMS & INCDENTS

Have you as Policyholder or the driver ever been convicted of any offence or received a fixed penalty notice?

Have you as Policyholder or the driver ever been involved in an accident?

Have you as Policyholder or the driver ever been involved in any other claim or incident in connection with a motor vehicle?

Have you as Policyholder or the driver ever been refused insurance or had any insurance cancelled or been refused renewal?

Have you ever suffered from any physical or mental disability?

• If the answer to any of the questions above is 'YES', please give full details below.

01

Date:

Driver:

Circumstances/Details:

Conviction Code:

Fine:

02

Date:

Driver:

Circumstances/Details:

Conviction Code:

Fine:

03

Date:

Driver:

Circumstances/Details:

Conviction Code:

Fine:

PHYSCIAL / MENTAL DISABILITY

Describe any physical/mental disability (if applicable):

DETAILS OF INSURED VEHICLE OR VEHICLE BEING DRIVEN AT THE TIME (STEP 3 / 8)

VEHICLE

Registration number:

Year of make:

Make and exact model:

Colour:

CC (or GVW if CV):

Mileage (if known):

Current value:

Is the vehicle owned by the Policyholder?

Is the vehicle registered in the Policyholder’s name?

If the answer to either of the above questions above is 'NO', give full details of the owner / keeper and relationship to owner / keeper:

Date of purchase:

Purchase price (£):

Has the vehicle been modified in any way?

If you answered 'YES' above, give details:

Is the vehicle installed with telematics or dashcams?

If you answered 'YES' above, give details (and provide report/footage):

HIRE PURCHASE / LEASE

Is the vehicle subject to Hire Purchase or Lease?

If you answered 'YES' above, give full name and address of Finance / Leasing Company:

Postcode:

Telephone number:

HP Agreement No / Lease Contract No:

Note: In the event of a total loss, settlement of the claim will be paid to the Finance / Leasing Company.

DETAILS OF DAMAGE (STEP 4 / 8)

Do you wish to claim for your vehicle damage through your policy?

Describe the damage to your vehicle:

Main area of impact to the vehicle?

If 'other' to the above - please describe:

Estimated repair cost (£):

Is the vehicle at the repairer’s now?

If 'NO' to the above - where is it?

Repairer’s Name:

Repairer’s Telephone Number:

Repairer’s Fax Number:

Repairer’s Address:

Postcode:

If 'NO' do you have another repairer you would prefer, and if so, give details?

DETAILS OF EXACT USE OF VEHICLE (STEP 5 / 8)

State EXACT USE of vehicle (if vehicle was not being driven, then state use prior to parking and the journey destination):

Please Note: ‘Social / Pleasure’ are not adequate explanations; a detailed description of journey and usage is required.

Name(s) of passenger(s) carried and approximate ages (yrs):

Were any goods being carried?

DETAILS OF ACCIDENT (STEP 6 / 8)

Date:

Time:

Weather conditions:

Road conditions:

Exact location (Road, Town / County):

Speed limit (MPH):

Width of road:

YOUR VEHICLE

Speed of vehicle prior to accident (MPH):

Distance from nearside kerb:

What lights were displayed:

What signals where given:

What warnings where given:

THIRD PARTY VEHICLE (IF APPLICABLE)

Speed of vehicle prior to accident (MPH):

Distance from nearside kerb:

What lights were displayed:

What signals where given:

What warnings where given:

ACCIDENT DETAILS

Briefly state in your opinion who was to blame and reason(s):

Describe fully how the accident occurred:

Sketch Plan - Draw a sketch of the road(s) showing the position of the vehicles at the point of impact. Indicate directions by arrows. Please show road signs/markings and directions of nearest towns. Then take a photo / scan / upload/attach.

DETAILS OF OTHER VEHICLES OR PERSONS INVOLVED (STEP 7 / 8)

OTHER VEHICLE 01

Make and Registration Number of Vehicle:

Name and Address of Owner and or Driver:

Details of Insurers / Policy number:

Damage to their Vehicle:

No. of Occupants in Vehicle:

OTHER VEHICLE 02 (if applicable)

Make and Registration Number of Vehicle:

Name and Address of Owner and or Driver:

Details of Insurers / Policy number:

Damage to their Vehicle:

No. of Occupants in Vehicle:

OTHER VEHICLE 03 (if applicable)

Make and Registration Number of Vehicle:

Name and Address of Owner and or Driver:

Details of Insurers / Policy number:

Damage to their Vehicle:

No. of Occupants in Vehicle:

WITNESSES (if applicable)

01 - Name and Address of Own Passengers:

02 - Name and Address of Own Passengers:

01 - Name and Address of Any Other Witnesses:

02 - Name and Address of Any Other Witnesses:

REPORTING & INJURIES

Was the accident reported to the Police

If answer to the above is 'YES', what was the Reporting Officers Name and Number?

Police station and address:

Any prosecution likely?

If answer to the above is 'YES', give full details and against whom:

Was any person breathalysed?

If answer to the above is 'YES', whom was breathalysed?

Result of test (if applicable):

Was any person injured?

If 'YES' - whom was injured?:

Give details of whom was injured:

PERSON INJURED 01 (if applicable)

Brief description of person injured:
(E.g. female front passenger complaining of concussion)

Approx Age:

Nature of injuries:

Seat belt worn?

PERSON INJURED 02 (if applicable)

Brief description of person injured:
(E.g. female front passenger complaining of concussion)

Approx Age:

Nature of injuries:

Seat belt worn?

Was any person taken to Hospital?

If 'YES' to the above - name and address of hospital:

Do you know if they were detained?

Additional Information Sheet Attachment/Upload (if applicable)

Any claim against you, including any communication from the police or from any hospital authority, must be passed to us immediately without acknowledgement.

DECLARATION (STEP 8 / 8)

You must read the declaration before submitting.

I/We declare that the above statements are true and correct to the best of my/our knowledge and belief. I/We hold no other policy in addition to this one indemnifying me in respect of this claim. I/We have not withheld from the Insurers any information within my knowledge connected with the loss and I/we agree to provide the Insurers with any further information or documentation as may be required. If my/our vehicle is a total loss I/we agree that the company have my permission to remove the vehicle to safe and free storage pending the completion of their investigations and any settlement of this claim. I/We understand that any attempt to make a fraudulent accident claim will result in prosecution.

By completing the following, and submitting this form, you agree to the above statements and information provided.

Name of Driver or Last Person in Charge of Vehicle:

Date:

Name of Policyholder:

Date:

Signatures:

If applicable - if this form has been compiled by another party on behalf of the Policyholder, will the compiler please complete the section below.

Name:

Occupation:

Address:

Postcode:

DOCUMENTS REQUIRED

Please make sure you supply us with the following documents to review your claim, failure to provide these documents will potentially cause delays.

• This Claim Form
We will receive this once you submit this online form.

• Copy of Driver’s Licence (good photocopy) & DVLA checker
Upload 01:

Upload 02:

• Policy Number (if known)
This will be required to review your claim.

Additional documents required for total loss claims (email these documents to us if required):

• Vehicle Registration Book
• MOT Certificate
• Vehicle Keys
• Purchase receipt for vehicle
• Any documents to establish value & condition of vehicle
• Photographs of vehicle if available

Please note: Once you have clicked the submit button, do not refresh the page and please allow a moment for the form to send. A confirmation message will appear once complete. You will also receive a confirmation email with all the details you have submitted.

If an error message appears when submitting, check all information is correct and try submitting again.