Claim Number (if known) POLICY HOLDER Name: Address: Postcode: Telephone No: Mobile No: Email Address: Occupation: Policy/Certificate Number: Depot Number: Can we contact you by SMS? YesNo Are you registered under the VAT Regulations? YesNo INSURED VEHICLE Make: Model: Registration: Year of manufacture: Description of damage: Address where vehicle is currently located: Estimated cost of repair (if known) £ Purpose for which vehicle was being used: Nature and weight of any load carried: Was the vehicle towing? YesNo Is vehicle fitted with Telematics? YesNo DRIVER/PERSON IN CHARGE OF INSURED VEHICLE Name: Address: Postcode: Telephone No: Mobile No: Email Address: Occupation: Age and date of birth: Type of Licence held: Licence held for less than 12 months: ---YesNo Can we contact you by SMS? YesNo 1. Has the driver been involved in any motor accident or had a vehicle damaged or stolen, regardless of who was at fault or whether a claim was made, within the past five years? YesNo 2. Does the driver have any pending prosecutions, ever been prosecuted or incurred a Fixed Penalty for an endorsable offence in connection with a motor vehicle in the last five years? YesNo 3. Has the driver ever had a Motor policy cancelled, declined, declared void, refused renewal or asked to bear special terms or conditions? YesNo 4. Does the driver have defective vision or hearing (not corrected by glasses or hearing aid), diabetes, or any disease or physical or mental infirmity, or fits of any kind? YesNo 5. If not the Policyholder, did the driver have the Policyholder’s permission to drive? YesNo If answer to question 1, 2, 3, or 4 is ‘Yes’, please give details THIRD PARTY-OTHER DRIVER(S) AND VEHICLE(S) INVOLVED Name: Address: Postcode: Telephone No: Mobile No: Name/Address of insurers Postcode: Policy/Certificate No.: Registration No.: Make and Model of Vehicle: Number of passengers in Vehicle: Description of damage to other Vehicle or Property: Injured Person(s) Name: Address: Nature of Injuries sustained: Apparent Age: State whether occupant of Insured car, other car, or pedestrian: Name: Address: Nature of Injuries sustained: Apparent Age: State whether occupant of Insured car, other car, or pedestrian: Particulars of Hospital or Doctor attending injured person(s): WITNESSES Names and addresses of all independent Witnesses Names and addresses of passengers in Insured Vehicle Were particulars taken by a Police Officer? If so, please provide the Police Officer name, number and station details ACCIDENT Date: Time: Place: State of roads: Weather conditions: Was anyone tested for drink or drugs? YesNo If yes, please confirm name(s) and result(s) if known Your Vehicle Other Vehicle Estimated Speed Position in road What lights were used Did vehicle suffer any mechanical or non mechanical failure? ---YesNo If yes please give details Are there any photographs available of the damage sustained to the Vehicles involved? YesNo Who do you consider at fault? Description of Accident Please provide a sketch of the accident here Note to Help You If anyone has been injured or if you have suffered a theft or malicious damage the matter must be reported to the police as soon as possible. Send immediately, unanswered, all correspondence you or the driver receive from others involved in the incident to your insurance advisor or your Allianz office. Getting your Vehicle Repaired If your vehicle is insured for the damage to it, you may put in hand any temporary repairs necessary to make it driveable. We will want to see any estimates and invoices for this work but do not delay submitting the accident report form. Approved repairers – We have a network of these, and we may have already suggested that you use them. Using one of our Approved Repairers will give you many advantages, such as: Free courtesy car/vehicle* Free collection and delivery of your vehicle* Priority service and speedy repairs 5 year guarantee on all repairs Free wash and vacuum * For vehicles up to 3.5 tonnes gross vehicle weight We understand if you want to use a repairer of your own, although it is likely we would want to inspect your vehicle at the repairer’s premises at some point. Please telephone us with details of the repairer you want to use. For the address of our nearest Approved Repairer’s please telephone your insurance advisor or Allianz’s nearest office. Beyond Economic Repair – If your vehicle proves to be too badly damaged to repair economically we will need the following: • Your Registration Document (V5) • Your current MOT certificate (if applicable) • Your original purchase receipt, if possible • Certificate of insurance • Any service or repair accounts • Any sets of keys Notice Insurers pass information to the Claims and Underwriting Exchange Register and the Motor Insurance Anti-fraud and Theft Register run by Insurance Database Services Ltd. (IDS Ltd). The aim is to help us check information provided and also prevent fraudulent claims. Under the conditions of your policy, you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. We may pass information related to this incident to the registers. Data Protection Notification We may use the personal and business details you give us, or which are supplied by third parties, to consider your claim, search the files of credit reference agencies who may keep a record of the search, to carry out such financial and other enquiries as we may consider necessary to evaluate the claim and assist in making a decision regarding the claim, and for compliance business reviews. We may also share these details with other insurance organisations and selected other parties to handle claims and prevent fraud. Personal details may be transferred to countries outside of the EEA. They will at all times be held securely and handled with the upmost care in accordance with all principles of English law. We will store personal details on computer but will not keep them for longer than necessary. Under the terms of the Data Protection Act 1998, individuals are entitled to a copy of all the information we hold about them. Telephone calls may be recorded for our mutual protection, training and monitoring purposes. VERY IMPORTANT – FRAUDULENT AND EXAGGERATED CLAIMS Deliberately exaggerated claims could invalidate your policy cover. Insurance fraud is a crime and liable to prosecution. The above answers to our questions will be the basis of consideration of your claim. You must ensure that all information is true, correct and complete to the best of your knowledge and belief. FAILURE TO DO THIS MAY RESULT IN YOUR POLICY BECOMING INVALID AND A CLAIM PAYMENT WILL NOT BE MADE. I/We declare that the particulars provided are correct to the best of my knowledge and belief. I/We understand that you may seek information from other insurers to check the answers I/we have provided. This report is made in the bona fide belief that litigation may ensue and to enable solicitors and/or agents to conduct such litigation and advise in relation thereto. Signature of Insured: Date:
