a b c d e f g h i j k l m n
Are you a litigant person?
Claimant's representative - contact details Defendant's details
Name Defendant's name
Address Defendant's address
Postcode Defendant's postcode
Contact name Defendant's vehicle registration number
Telephone number Policy number reference
E-mail address Insurer name
Reference number  
 
Title Is this a child claim?
Claimant's name National insurance number
Claimant's Address If the claimant does not have a national insurance number please explain why
Postcode Occupation
Date of birth (dd/mm/yyyy) Claimant's vehicle registration number
  Accident Date (dd/mm/yyyy)
 
   
1.1 What type of injury was suffered?
Soft Tissue Bone Injury Whiplash Other
Please provide a further brief description of the injury sustained as a result of the incident
1.2 Has the claimant had to take any time off work as a result of the injury?
Yes No
1.3 Is the claimaint still off work?
Yes No
If No, how many days in total was the claimant off work?
1.4 Has the claimant sought any medical attentions?
Yes No
If Yes, on what date did they first do so?
1.5 Did the claimant attend hospital as a results of the accident?
Yes No
If Yes, please provide details of the hospital(s) attended  
If hospital was attended, was the claimant detained overnight?  
Yes No
If Yes, how many days were they detained?
   
2.1 Has a medical professional recommended the claimant should undertake any rehabilitation such as physiotherapy?  
Yes No
If Yes, please provide brief details of the rehabilitation treatment recommended and any treatment provided including name of provider
2.2 Are you aware of any rehabilitation needs that the claimant has arising out of the accident?
Yes No
If Yes, please provide full details
     
3.1 Is the claimant claiming damage to their own vehicle? If No, goto section F  
Yes No
3.2 Details of the insurance cover held for the vehicle?
Comprehensive
Third party fire and theft
Third party only
Other
 
 
3.3 Is the claim for the vehicle damage proceeding through the claimant's insurer?
Yes No
If No, is the claim for the vehicle damage proceeding through an alternative company?
Yes No
If the claim is proceeding through an alternative company, please provide full details if known*
3.4 Is the vehicle a total loss or likely to be?  
Yes No Unknown
If No, what is the current position with the repairs?
Complete
Authorised
Not yet authorised
Not Known
 
3.5 Do you require the defendant's insurer to organise the repairs and/or inspection of the vehicle?
Yes No
If Yes, please provide contact details and where the vehicle is located  
     
(If the claimant has been provided with a vehicle by their insurer, please goto Section F)
4.1 Does the claimant require the use of an alternative vehicle?  
Yes No
4.2 Has the claimant been provided with the use of an alternative vehicle?
Yes No
If Yes, is the hire need still on going?
Yes No
4.3 If a vehicle has been provided, please give the following details:  
Name of provider  
Address of provider  
   
Reference  
Start date (dd/mm/yyyy)  
End date (dd/mm/yyyy)  
Vehicle registration number*  
Make*  
Model*  
Engine size (cc)*  
4.4 Do you require the defendant's insurer to provide your client with an alternative vehicle?  
Yes No
If Yes, please provide the following details:  
What type of vehicle is required?  
Contact name and telephone number  
   
4.5 Do you have legal expenses cover on your motor insurance policy or any other policy of insurance or credit card that you may have?  
Yes No
     
5.1 At the time of the accident the claimant was  
The driver
The owner of the vehicle but not driving
A passenger in or on a vehicle owned by someone else
A pedestrian
A cyclist
A motorcyclist
Other (please specify)
 
   
5.2 If the claimant was the driver or passenger, how many occupants were in the claimant's vehicle?  
5.3 If the claimant was the driver or passenger, was the claimant wearing a seatbelt?  
Yes No Seatbelt not supplied
5-4 If the claimant was a passenger please provide the detials of the driver and the owner of the vehicle in which the claimant was a passenger unless the driver is the defendent:
Driver's name*  
Address*  
   
Postcode*  
If owner not the driver, owner's name*  
Make and model of the vehicle*  
Vehicle registration number*  
Insurance company name*  
Address*  
   
Postcode*  
Policy number*  
     
6.1 Estimated time of accident (24 hour clock hh:mm)  
6.2 Where did the accident happen?  
6.3 Weather and road conditions    
Weather Conditions  
Sun
Rain
Snow

Ice

Fog
Other (please specify)
 
     
Road Conditions  
Dry
Wet
Snow

Ice

Mud
Oil
Other (please specify)
 
6.4 Please select the most accurate description of the accident circumstances from the list opposite  
Claimant vehicle hit by party emerging from side road
Claimant vehicle hit in the rear
Claimant hit whilst parked

Accident in a car park

Accident on a roundabout
Accident involving vehicles changing lanes
Concertina collision
Other
   
6.5 Please give us a brief description of the accident, including the approximate speeds of all vehicles and details of the areas of vehicle damage
6.6 Was the incident reported to the police?  
Yes No Not known
If Yes, please provide the following, if known:    
Name and address of police station*  
   
Name of reporting officer*  
Reference number*  
     
7.1 Details of the defendent and vehicle    
Full name  
Address  
   
Postcode  
Approximate age  
Sex  
Male Female Not known
Vehicle registration number  
Make  
Model  
Colour  
7.2 Description of defendant    
7.3 How were the defendants details obtained?    
     
8.1 If parties other than the claimant and defendant were invloved or there were witnesses please provide their details:
Other party  
Not applicable
Witness
Other (please specify)
 
 
Name  
Address  
   
Postcode  
Vehicle registration number*  
Vehicle make and model*  
Insurance company name*  
Address*  
   
Policy number*  
8.2 If parties other than the claimant and defendant were invloved or there were witnesses please provide their details:
Other party  
Not applicable
Witness
Other (please specify)
 
 
Name  
Address  
   
Postcode  
Vehicle registration number*  
Vehicle make and model*  
Insurance company name*  
Address*  
   
Policy number*  
8.3 If parties other than the claimant and defendant were invloved or there were witnesses please provide their details:
Other party  
Not applicable
Witness
Other (please specify)
 
 
Name  
Address  
   
Postcode  
Vehicle registration number*  
Vehicle make and model*  
Insurance company name*  
Address*  
   
Policy number*  
     
9.1 Where the accident involved a bus or a coach, please complete the following:
Driver name and ID number*  
Description of the driver*  
   
Description of the vehicle*  
please include route number
and direction of travel, type,
colour and markings of vehicle
 
Approximate number of
passengers on the bus or coach
 
9.2 Is evidence of travel available?  
Yes No
If No, please state why not
     
10.1 Why does the claimant believe that the defendant was responsible for the accident?
10.2 If the claimant believes that another party noted in Section I could bear some responsibility, please confirm which*
     
11.1 Has the claimant undertaken a funding arrangement within the meaning of the CPR rule 43.1(1)(k)?  
Yes No
If Yes, please tick the following boxes that apply:    
The claimant has entered into a conditional fee arrangement in relation to this claim, which provides for a success fee within the meaning of section 58(2) of the Courts and Legal Services Act 1990
Date conditional fee arrangement was entered into (dd/mm/yyyy)  
The claimant has taken out an insurance policy to which section 29 of the Access to Justice Act 1999 applies
Name of insurance company  
Address of insurance company  
   
Policy number  
Policy date (dd/mm/yyyy)  
Level of cover  
Are the insurance premiums staged?  
Yes No
If Yes, at which point is an
increased premium payable?
 
The claimant has an agreement with a membership organisation to meet their legal costs
Name of organisation  
Date of agreement (dd/mm/yyyy)  
Other, please give details
11.2 For MIB claims only - The claimant would like their claim to be considered for free legal expenses insurance  
Yes No
     
 
 
Your personal information will only be disclosed to third parties, where we are a re obliged or permitted to do so. This includes use for the purpose of claims administration as well as disclosure to third-party managed databases used to help prevent fraud, and to regulatory bodies for the purposes of monitoring and/or enforcing our compliance with any regulatory rules/codes.
Where the claimant is a child the acceptance below will be the child's parent or guardian or by the legal representative authorised by them
 
I am the claimants solicitor. The claimant believes that the facts stated in this claim form are true, I am duly authorised by the claimant to sign this statement.
I am the claimant. I believe that the facts stated in this form are true.
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