Step 1 of 14 - Policy Holder Details

Policy Holder Details

Policy Holder*

Policy Number*

Policy Holder Address*

Email Address for Claims Contact*

Phone Number*

VAT Registered?*

Yes

Driver Section

Driver Name*

Date of Birth*

DD dash MM dash YYYY

Date passed test to drive the vehicle concerned*

DD dash MM dash YYYY

If the Driver has any of the following conviction codes currently on their license, please provide full details - AC, BA, CD40 to CD90, DD, DR,, IN, LC, MS, TT, UT or XX

Known Medical Conditions*

Incident Details

Time of Loss

Hours

Minutes

AM/PM

Date of Loss*

DD dash MM dash YYYY

Accident Location*

Please be as specific as possible

Speed of all Vehicles involved*

Weather/Road Conditions*

Any Photographs taken?*

Yes

Upload photographs taken

Drop files here or

Max. file size: 256 MB.

Our Insured Vehicle

Vehicle Registration*

Make/Model*

Mileage*

CCTV/Dashcam footage available?*

Yes

Will you be claiming for damage to this vehicle?*

Yes

Vehicle damage description*

Vehicle driveable?*

Yes

Please indicate damage area to policyholder vehicle

Full Front End

Drivers Side Front

Drivers Side Rear

Passenger Side Front

Passenger Side Rear

Rear Tailgage/Bumper

Alloy Wheel

Interior

Engine

Exhaust

Other

Please provide the other areas where the vehicle is damaged.

Passengers/Injuries - Policy Holder Vehicle

How many passengers were in your vehicle?*

Names and Contact Details of any Passengers*

Was anybody in this vehicle injured, if so, what injuries have been sustained?*

Did an Ambulance attend the scene?*

Yes

Attended Hospital?*

Yes

Name of that Hospital

Sketch and Statement

Please Provide a Statement of the accident below and draw sketch on your paper and upload that sketch below as well*

Upload Sketch which you drawn on your paper

Drop files here or

Max. file size: 256 MB.

Do you consider yourself to be at fault for the incident?*

Partially

Yes

Third Party Details

Driver Name

Address. If incident involved a third party's property, please give full address details

Phone Number

Email Address

Third Party Vehicle Details

Vehicle Registration

Make/Model

Color

Insurance Details

Vehicle Damage Description

Any pre-existing damage?

Yes

Vehicle Driveable?

Yes

Please indicate damage area to vehicle

Full Front End

Drivers Side Front

Drivers Side Rear

Passenger Side Front

Passenger Side Rear

Rear Tailgage/Bumper

Alloy Wheel

Interior

Engine

Exhaust

Other

Please provide the other areas where the vehicle is damaged.

Third Party passengers/Injuries

How many passengers were in the third party vehicle at the time of collision?

Were any of the passengers minors?

(Under 16 years old)

Did anybody in this vehicle complain of, suffer or incur visible injuries at the scene?

If so, please provide full name and contact details if known

Did an ambulance attend the scene?

Yes

Witnesses (If applicable)

Witness Name

Phone Number

Email Address

Address

Independant?

Yes

Police Details (If applicable)

Did Police attend?

Yes

Office Name/Badge Number

Reference Number

Station

Did driver make a written statement?

Yes

Any other comments/concerns you may wish to make known?

Declaration

Declaration
I/We hereby declare that the above information and statements are true to the best of my/our knowledge and belief. I/We understand that you may ask for information from other Insurers to check the answers I/We have provided. No other insurance is in force and I/We will assist TempDrive Services LTD with their esquires.

Signature:*

Date*

DD dash MM dash YYYY

Claim Number

Claim no

Your Claim Number is going to be sent to you via upcoming email in PDF format. Please note it down for future correspondence. You will be assigned a Claims Handler, who will shortly be in touch with you. Also, click on Submit form button to proceed further. Thank You

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Accident Report Claim

Policy Holder Details

Driver Section

Incident Details

Our Insured Vehicle

Passengers/Injuries - Policy Holder Vehicle

Sketch and Statement

Third Party Details

Third Party Vehicle Details

Third Party passengers/Injuries

Witnesses (If applicable)

Police Details (If applicable)

Any other comments/concerns you may wish to make known?

Declaration

Claim Number

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