MOTOR CLAIM FORM. Policy Number Claim Number Your reference. Make and model Vehicle c.c. Year of manufacture

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1 PLEASE ANSWER EVERY QUESTION. MOTOR CLAIM FORM Policy Number Claim Number Your reference INSURED Post code Telephone Number Department Concerned (Code and Description) VAT registered / status? VEHICLE Type (Code and Description) Make and model Vehicle c.c. Year of manufacture Registration number DRIVER Is vehicle owned/hired/leased/loaned? (Code and Description) Telephone number Date of Birth Is driver employed by you? Department Was driver authorised? Purpose of journey Any convictions for motoring offences? Any charges pending? If so, state details and dates What Occupation is the Driver in? (Code and Description) Type of licence (Code and Description) And years held How old is the driver?

2 Claim Number ACCIDENT Date Time Weather conditions Speed of your vehicle before accident What lights were showing? Speed limit Speed of your vehicle at moment of impact Was any warning given? What was the Vehicle being used for? (Code and Description) State the cause of the Accident (Code and Description) OWN DAMAGE Description of damage (Code and Description) Approximate cost of repair (Please attach estimate where applicable) Where can it be inspected? CLAIMANT Description of Injury (Code and Description) Claimants Occupation (Code and Description) Claimants Employment Status (Code and Description) Age Date Ceased Work Date Resumed Work Date Left Work OTHER VEHICLES INVOLVED and address of owner (including postcode) PostCode Registration number Make and model Insurer s name Insurer s Policy / Certificate number Apparent damage

3 SOLICITORS DETAILS Solicitors Solicitors Solicitors Solicitors Solicitors Solicitors Solicitors Postcode Solicitor Ref Claim Number THE ROAD Classification of road, i.e. trunk, class I, II, III, unclassified, footpath or bridleway (Code and Description) What sort of Area is the road in? (Code and Description) PROPERTY DAMAGED/INJURED PERSONS (if passengers, please state in which vehicle) Description of property Extent of damage Injured persons:state name and address (wheth. driver, pedestrian); details of injury; medical attention needed; name of hospital WITNESSES Please state whether independent or passengers in your vehicle POLICE Were the Police informed? Did they attend? Are proceedings pending? If so, against whom? Give name and number of officer Give address of station

4 This section MUST BE completed Claim Number Please fill box as appropriate Customer code where applicable HOU BLD CLG CMS EVS CPS GDM HHS PGD PPY CTG GML MAG PKO PCT BUC RLS SIS ETN RSE VEH WTD FDT POL ITS ERD SPH AIR OTH Housing (including maintenance) Building (excluding Building control) Street Cleansing Cemeteries and Crematoria Environmental Services (excluding Refuse/Street Cleansing) (including Dog Wardens/Pest Control) Corporate services Grounds Maintenance Highways Planning/Development/Tourism Property (other than housing)/car Parks/Public Conveniences Catering Galleries/Museums/Libraries Magistrates/Probation/Coroners Parks/Open Spaces Public/Community Transport Building Control Recreation Leisure Social Services Education Refuse Collection Vehicle Repair / Maintenance Waste Disposal Fire Service Police Service Computer / I.T. Elections / Electoral Registration Sea / Coastal Protection / Harbours Airports Other (No Council Function Firework Displays, Parties, etc.)

5 Claim Number I declare that all answers are true and correct Signature Date Designation Additional information ZURICH MUNICIPAL IS A TRADING NAME OF ZURICH INSURANCE COMPANY. A LIMITED COMPANY INCORPORATED IN SWITZERLAND. REGISTERED IN THE CANTON OF ZURICH. NO UK BRANCH REGISTERED IN ENGLAND. NO. BR105. A MEMBER OF THE ASSOCIATION OF BRITISH INSURERS. UK HEAD OFFICE: ZURICH HOUSE, STANHOPE ROAD, PORTSMOUTH, HAMPSHIRE PO1 1DU.

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