Road Traffic Accident Claim Form

1. Accident Overview

Country *

Date of accident *

Time (24hr)

Number of occupants in your vehicle

Weather conditions

Location of accident *

Heads of claim (tick all that apply)

Personal Injury Vehicle Damage Hire Vehicle Storage

Description of accident

2. Your Details

Title

Full name *

Date of birth

NI number

Occupation

Phone *

Email *

Address *

Postcode *

Evidence at scene

Photos taken at the scene

3. Injury & Medical

Injury details

Hospital attended (name)

Hospital stay

Stayed overnight in hospital

Time off work?

GP visit

Attended GP after the accident

Date of GP / hospital visit

4. Your Vehicle

Registration

Make & model

Insurance company

Policy number

Damage to your vehicle

Repair position

Excess (£)

5. Third Party

Name

Phone

Address

How were their details obtained?

TP vehicle registration

TP make & model

TP insurance company

6. Police

Police attendance

Police attended the scene

Police informed

Police informed after the accident

Police station

Officer name

Police reference

7. Witnesses

Anyone independent who saw the accident.

Witness 1, name

Witness 1, phone

Witness 1, email

Witness 2, name

Witness 2, phone

Witness 2, email

8. Hire & Storage

Hire company (name & phone)

Hire, from

Hire, to

Storage company (name & phone)

Storage, from

Storage, to

Daily rate (£)

9. Passengers

Anyone in your vehicle at the time of the accident.

No passengers added.

10. Supporting Evidence

Optional. Photos of the scene and vehicle damage, hospital / GP letters, hire and repair invoices, ID and proof of address all strengthen your case pack.

Supporting evidence (optional)

Add up to 10 photos or documents. Max 8MB per file. JPG, PNG, HEIC, PDF, DOC.

No files selected

11. Final Details

Anything else we should know?

Preferred contact method

EitherPhoneEmail

Previous legal advice

I have already spoken to another solicitor about this

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We will contact you within 24 working hours to progress your case pack.

Road Traffic Accident, Claim Intake Form