CLAIM FORM (page 1) Name:.. Address:...Post Code:... Sex M/F D.O.B. Age:... Tel:.. Mobile:. Occupation:. Name & Address of Employer:..
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1 CLAIM FORM (page 1) DRIVER DETAILS Address: Post Code:..... Sex M/F D.O.B. Age:... Tel:.. Mobile:. Occupation:. Name & Address of Employer:.. NI No:. CAR DETAILS Registration No:... Make & Model:... Insurance Co:.. Type of Cover: Policy No:... THIRD PARTY CAR DETAILS Registration No:... Make & Model:... Insurance Co:.. Type of Cover: Policy No:... POLICY DETAILS Address: Post Code:..... Sex M/F D.O.B. Age:... Tel:.. Mobile:. Occupation:. Name & Address of Employer:.. VAT Registered Yes/No WITNESS DETAILS Witness 1... Tel No Witness 2... Tel No Witness 3... Tel No THIRD PARTY DETAILS Address:. Tel:.. Mobile: ACCIDENT DETAILS Date: Time:.. Road Conditions: Wet / Dry Description:
2 CLAIM FORM (page 2) SKETCH POLICE DETAILS Did police attend: Name:. Reference No: Address:.... Tel No: INJURY INFORMATION Shock and shaking up: Whiplash: Bruising: Cuts & Grazes: Bang to the head: (PLEASE CIRCLE INJURY SUSTAINED BY YOU) (if yes please provide details. i.e. how did this effect you, e.g. stomach churning, shaking, nervous in vehicle) (if yes please provide details. i.e. neck, neck and back, or back) (if yes please provide details. i.e. which part of the body) (if yes please provide details. i.e. which part of body cut or grazed) (if yes please provide details. i.e. how severe was the impact e.g. concussed, headache, dizziness etc) HEADS OF CLAIM Client claiming for (please circle) Injury Loss of earning Excess Hire Car Cash in Lieu Other Is the vehicle legally drivable; is the vehicle repairable: DECLARATION & SIGNATURE I hereby confirm that the information I provide is the best of my knowledge. I hereby authorize Accident-@ll or its duly appointed solicitors to act on my behalf. I confirm that I have no other solicitor already acting for me or whom I wish to give construction Print Name:. Signed:.. Date:
3 Passenger Claim Form (page 1) Address:... Post Code:..... Tel:.. D.O.B.:... Age:.. Sex: Male / Female N.I.:..... ACCIDENT DETAILS Date of Accident:.... Time of Accident:... Position in vehicle:. Occupation: Name of Employer: Address of Employer: Post Code: VAT Registered: Name of Driver:. Registration of car: INJURY INFORMATION Shock and shaking up: Whiplash: Bruising: Cuts & Grazes: Bang to the head: (PLEASE CIRCLE INJURY SUSTAINED BY YOU) (if yes please provide details. i.e. how did this effect you, e.g. stomach churning, shaking, nervous in vehicle) (if yes please provide details. i.e. neck, neck and back, or back) (if yes please provide details. i.e. which part of the body) (if yes please provide details. i.e. which part of body cut or grazed) (if yes please provide details. i.e. how severe was the impact e.g. concussed, headache, dizziness etc) HEADS OF CLAIM Client claiming for (please circle) Injury Loss of earning Excess Hire Car Cash in Lieu Other Is the vehicle legally drivable; is the vehicle repairable: DECLARATION & SIGNATURE I hereby confirm that the information I provide is the best of my knowledge. I hereby authorize Accident-@ll or its duly appointed solicitors to act on my behalf. I confirm that I have no other solicitor already acting for me or whom I wish to give construction Print Name:. Signed:.. Date:
4 Passenger Claim Form (page 2) ACCIDENT DETAILS Description:......
5 WITNESS STATEMENTS WITNESS (1): WITNESS (2): WITNESS (3): WITNESS (4): WITNESS (5): WITNESS (6): WITNESS (7):
6 MEDICAL AUTHORITY FORM... DATE OF ACCIDENT:.. DATE OF BIRTH: TEL NO:.. NAME OF GP:. FULL POSTAL ADDRESS OF GP:... TEL NO: NAME OF HOSPITAL ATTENDED:. ADDRESS OF HOSPITAL ATTENDED: I authorise release of copies of my GP notes and hospital records or any other documents, x-rays or scans to the solicitors whom are representing me or any consultant instructed by them. With reference to general practitioner notes please provide: 1. copies of the entire paper held records 2. old print-outs from previous systems 3. entire print out from the current systems, including scanned items and results The name of the computer system in use. It is confirmed that no legal; proceedings are contemplated relating to the provision of such medical treatment as may have been administered as a result of such accident. Please note that this request to m medical records is made pursuant to s.7 of the Data Protection Act 1998 and the Data Protection (subject access) (fees and Miscellaneous provisions) regulation 200 ( the Regulator) whereby I authorise any solicitor representing me to have access to all notes, records, x-rays and other documents relating to advice or treatment given to me or copies of all such documents. I confirm that my solicitors will pay your reasonable charges up to the maximum prescribed by the regulation. SIGNED: DATE:
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