Claims Submission Demo

Before starting the form, please ensure that you have all details and documents to complete this report. Documents can be uploaded within this report, documents required are:
- Copy of both sides of the Driver’s Driving License
- Drivers DVLA Summary
- Camera Footage (where available)
- Telegraphic data (where available)
- Photographs

Client / Company Name*

Are you VAT Registered?*

Name of individual completing report*

First Last

Did Driver or Driver last in charge of vehicle, have Clients permission?*

Drivers Full Name or driver last in charge of vehicle*

First Last

Drivers Date of Birth*

Is Driver Employed or Agency?*

Name of Agency that driver employed via*

What date did Driver pass test for Class of vehicle?*

Depot Driver Assigned to?*

Does the Driver have any convictions?*

List Convictions*

Date

Conviction

Points/Charge

Does the Driver have any DVLA notifiable medical Conditions or disabilities?*

List Conditions*

Condition

Date From

Upload copy of both sides of Drivers Licence*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.

Upload DVLA Summary*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.

Vehicle Registration*

Vehicle Make and Model*

Is the vehicle on lease / finance agreement?*

Please confirm what, if any, pre existing damage there is to your vehicle

What was the overall condition of your vehicle prior to the accident?*

Does the vehicle have a camera fitted?*

Upload Footage*

Drop files here or

Max. file size: 1 GB.

Is there Telematic data for vehicle?*

Upload Telematics*

Drop files here or

Max. file size: 1 GB.

Is the Report for an Accident or Theft?*

Date of Theft*

Time of Theft*

:

Police Station Reported to?*

Police Incident Reference Number*

Date reported*

Last known location of vehicle prior to theft*

Was this in a locked area?*

Please detail point of entry and any damage*

Is there any CCTV or Ring Doorbell footage?*

Upload CCTV Footage

Drop files here or

Max. file size: 1 GB.

Has the vehicle been recovered?*

Date of Incident*

Time of Incident*

:

Location of Incident*

Speed at time of accident*

Road Speed Limit*

Weather conditions*

Road Conditions*

Were Emergency Services called?*

Emergency Service Location*

Incident Reference Number*

Date Emergency Reported*

Is there damage to your vehicle?*

Describe the damage done to the vehicle.*

Do you wish to claim for damage to your vehicle?*

Do you have photographs of damage?*

Photos of Damage*

Drop files here or

Max. file size: 1 GB.

Is the vehicle Mobile/Road worthy?*

Where is the vehicle located to arrange an inspection*

In respect of the repairs, do you require our recommended Specialist Repairer to contact you?*

Please provide full Description of events*

Who do you consider to be at fault for this incident and why?*

Is a Third Party/s involved?*

Third Party Details*

Name

Address

Telephone

Registration

Insurer Details

Are there any Witnesses?*

Witness Details*

Name

Address

Telephone

Registration

Insurer Details

Do you have any further documents to upload, such as sketch etc?*

File

Drop files here or

Max. file size: 1 GB.

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Claims Submission Demo

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