I am * The Insured/PolicyholderA relative of the Insured/Policyholder
First Name *
Last Name *
Your Email *
Telephone Number *
Vehicle Registration *
Type of claim * ---Accident - vehicle is driveableAccident - vehicle is not driveableFireTheftVandalisedWater damageWindscreen
Date of incident *
Time of incident * AMPM
Were you in charge of the vehicle at the time of the incident? * YesNo
Were you or any third party injured? * YesNo
If yes, please give a brief description of the injuries below:
Where did the incident happen? *
Please be as specific as possible. For example: Junction 8, A217 / North end of West Street, Carshalton, Surrey.
Were the emergency services involved?* NonePoliceAmbulanceFire Brigade
Please tick all that apply.
Postcode of your vehicles current location
Passengers side Front wingFront doorRear doorRear wing
Drivers side Front wingFront doorRear doorRear wing
Centre FrontBonnetFront window/screenRoofRear window/screenBootRear
You can upload up to three (3) photographs of vehicle damage below:
Do you have details of the third party(ies) involved?* * YesNo
Please provide a brief description of the incident* *
Please give a brief description of the incident circumstances (including time of day, weather conditions, whether any third party was involved etc). For example: "I was travelling down West Street in Carshalton at 30mph at 2pm with two customers in the back when a pedestrian ran out in front of me. I had to brake harshly to avoid a collision and the vehicle behind went into the back of me. It had been raining that morning so the road was wet. I have the details and telephone number of the driver and the two customers. I asked them if they were okay and they said at the time that they were fine".