Accident Claims Form

Client details

Client vehicle details

Make/model Registration * Name of vehicle driver * Name of vehicle owner *

Address of vehicle owner * Postcode of vehicle * Was the client the driver of the vehicle? * Yes No

Client/driver insurance details 

Insurance company * Policy number * Address of insurance company

Insurer's telephone number

GP details

GP name GP address

GP's telephone number

Date attended * 

Hospital details

Did you attend hospital? * Yes No

Hospital name

Attendance date * 

Hospital address Hospital telephone

Heads of claim * (tick all that apply)

Storage and recoveryLoss of vehicle use HireTravel expenses

Hire provider details

Hire provider name * Hire provider address Hire provider telephone number *

Hire start date *

Hire reference number

Storage 

Storage yard name * Storage yard address

Dates vehicle stored (DD/MM/YYYY - DD/MM/YYYY) *

Employment details

Employer's name Employer's address

Employer's telephone Number of days off work

Accident details

Accident date & time * Accident location *

Weather conditions Number of passengers in vehicle *

Passenger details

Passenger 1

NameAddress Telephone

Passenger 2

NameAddress Telephone

Passenger 3

NameAddress Telephone

Passenger 4

NameAddress Telephone

Police Attendance

Did the police attend the accident? * Yes NoPolice officer's name

Police station address Reference number

Description of accident

Tell us how the accident happened *

Other accident circumstances

Third party/driver at fault details

Name * Address Telephone Vehicle make/model *

Vehicle registration * Insurance company * Telephone Policy number *

Client - previous accidents

Accident date

Client's registration Third party's registration Previous solicitors Previous solicitors reference

Accident date

Client's registration Third party's registration Previous solicitors Previous solicitors reference

Where did you hear about us?

Tell us where you heard about us *