HIGHWAY INCIDENT CLAIM FORM Please read the information provided before completing this form

Transcription

1 Page 1 of 6 S HIGHWAY INCIDENT CLAIM FORM Please read the information provided before completing this form Please report any dangerous defects to the Surrey Highways team as soon as possible by logging on to or if you think this may be an emergency situation, please call the Contact Centre immediately on Surrey County Council has a duty to protect public funds. Any claims where fraud is suspected will be investigated and appropriate action taken when fraud is detected. In the event that a claim is successful we can only pay for fair, reasonable and recoverable losses arising directly as a result of the accident; administration costs cannot be reimbursed e.g. postage, photocopying etc. Please make sure you provide as much information as possible about your incident to enable us to investigate your claim as quickly and efficiently as possible. We request that you date any photos of the damage incurred and the defect where possible. It is important to note that we cannot investigate claims without a precise location and date. 1. CLAIMANT DETAILS A cover letter describing the incident in full is recommended. Title...First Name... Last Name... National Insurance Number.. Date of Birth / / (Please note this information is required to prevent fraudulent claims and for national auditing purposes) Full Address:..... Postcode:... Daytime Contact Number. Mobile Phone Number.. Address *We regret that we cannot routinely correspond via , however would request your consent to contacting you via (or mobile telephone) should we consider it appropriate to do so for the purposes of processing your claim efficiently. 2. VEHICLE DETAILS PLEASE PROVIDE COPIES OF THE FOLLOWING DOCUMENTS: Vehicle Registration Document/Proof of Ownership Insurance Certificate MOT Certificate (if required for the vehicle) Proof of Last Service FOR OFFICE USE ONLY: FIGTREE REF:.... AREA CODE

2 3. INCIDENT DETAILS Page 2 of 6 You should include full incident details, cause of damage and reasons why you consider the authority to be at fault (please use further sheets if necessary or use the space on page 4) Did you report the defect? Yes / No Reference number:... Date of Incident / / Weather Conditions. Time of Incident... am/pm Speed... Have you advised your insurers about this incident? LOCATION DETAILS Road Name and Town (e.g. London Road, Guildford).. Nearest point of reference (Please supply a house number/name or significant landmark nearest to where the incident occurred - e.g.: Outside number 12 or opposite Post Office etc- and a map with the defect marked with an x or photos showing the defect or repair and surrounding area).... If there is no significant point of reference nearby you must supply a map marking the location. If this is not provided a site meeting will be required and the specific defect identified on site. Direction of Travel (e.g. eastbound between High Street and London Road or from Merrow to Guildford etc)

3 5. SKETCH PLAN Page 3 of 6 Provide a map or draw a sketch plan showing the precise location. 6. TOTAL COST CLAIMED (You must enclose copies of two independent estimates for work unless work was required immediately in which case please provide copy of invoice for work the original invoice will be required in the event of a successful claim. We cannot pay the costs of making a claim) 7. DAMAGE DETAILS Wheel / Tyre Damage - Front Left / Front Right / Rear Left / Rear Right (Circle as appropriate) Mileage covered by damaged tyre(s) before the incident Date tyre last changed before the incident (with supporting evidence) / / (As a publicly funded body we have a responsibility to spend as efficiently as possible. This means we are unable to replace an old tyre with a new one. A fair deduction is usually made in respect of wear and tear in the event of a successful claim.) Other damage suffered:..

4 Page 4 of 6 Please provide any further details that are relevant to your claim: 8. WITNESS DETAILS Were there any witnesses to this incident? Witness 1 Name... Address... Tel Witness 2 Name... Address... Tel POLICE DETAILS Were the police contacted/informed of the incident? Yes / No Police reference number:...

5 10. ENCLOSURES CHECKLIST (Please only send copies) Page 5 of 6 VEHICLE REGISTRATION DOCUMENT INSURANCE CERTIFICATE MOT CERTIFICATE (IF REQUIRED FOR THE VEHICLE) PROOF OF LAST SERVICE REPAIR INVOICE OR TWO ESTIMATES MAP MARKING EXACT LOCATION OF THE INCIDENT WITH AN X DATED PHOTOGRAPHS OF DEFECT / REPAIR AND SURROUNDING AREA DATED PHOTOGRAPHS OF THE DAMAGE ONCE YOU HAVE COMPLETED AND SIGNED THIS FORM PLEASE RETURN TO: Insurance Services G59 County Hall Penrhyn Road Kingston upon Thames Surrey KT1 2DN by insurance@surreycc.gov.uk WHEN WE RECEIVE YOUR CLAIM WE WILL Acknowledge your claim within 14 days and inform you if we require any further information. Within a further 90 days from the date of acknowledgment (providing we have the full information) your claim will be investigated and we will inform you if we have accepted or refuted your claim. INFORMATION REGARDING SURREY COUNTY COUNCIL CLAIMS Where a claim has occurred as a result of works carried out on the highway by a utility company or contractor your claim may be against them and not Surrey County Council. Subsequently information relating to your claim may be passed on to any relevant third parties (such as a contractor, or an insurer) solely for the purpose of processing a claim. In law for a claim against the highway authority to succeed it is necessary for the claimant to prove that - The highway in question has not been maintained appropriately, with regard to its importance and was therefore dangerous and this was the direct cause of their accident. If this can be proved, then it is for the highway authority to demonstrate that it took all reasonable steps to ensure that the highway was safe. In practice, this means that all records of inspections and repairs carried out form the basis of the authority s legal defence against any claim.

6 Page 6 of 6 Privacy Notice Surrey County Council is the data controller for the purposes of the Data Protection Act This means that Surrey County Council is responsible for making decisions about how your personal data will be processed and how it may be used. Personal information you provide will be treated confidentially at all times and may be used in a number of ways, in particular for the following purposes: Making decisions about whether to settle or reject your claim The resolution of disputes through the courts The detection and prevention of fraud Compliance with the legal and regulatory requirements In connection with the above we may share your information with: Our insurers, insurance brokers and loss adjustors Other local authorities Contractors and utility companies Government departments and agencies such as the Driver and Vehicle Licensing Agency (DVLA), the Vehicle & Operator Services Agency (VOSA) and the motor insurer s bureau (MIB). Security safeguards apply to both manual and computerised held data, and only relevant staff/named disclosures can access your information. Surrey County Council is under a duty to protect the public funds it administers and, to this end, may use the information you have provided on this form for the prevention and detection of fraud. We may also share this information with other bodies responsible for auditing or administering public funds for these purposes, including the Audit Commission. For further on how we process personal data please visit our website: Please read and sign the declaration below Statement of Truth I believe the facts stated in this Highway Incident Claim Form are true. I have read and understand the Privacy Notice and authorise Surrey County Council to carry out any necessary enquiries to verify the information I have provided. I will notify the Council immediately if there are any changes to the above information. Signed. Name Date