Details of Policyholder
Name:  
Occupation/Business:
Address:  
Postcode:
Tel:  
Fax:
Mobile:
Policy or Certificate No:
Vehicle/Use
Make:
Model:
Registration No:
Year first registered:
Engine Capacity:
Chassis No:
Give details of any trailer and/or loose container:
Is the vehicle, trailer or container owned by policyholder?
If not give details of owner:  
Was the vehicle being used on policyholders order or with permission?  
For what purpose was the vehicle being used?
If commercial vehicle, Gross Vehicle Weight:
Particulars of Driver
Name:
Age:
Address:
Postcode:
Date passed driving test:
Type of licence held:
If licence issued outside Great Britain, Northern Ireland or Channel Islands, state how long held: years
If driver is not policyholder give details of relationship e.g. employee, family relation, friend:
Has driver (a) been convicted of any driving or motoring offence within the last 5 years or is any prosecution pending?
If 'YES', please give full details including the date, offence code and penalty points:  
(b) been involved in an accident during the last 5 years?
If 'YES', please give details:  
If private car, who is the main user?
Details of Damage to the Policyholder's Vehicle
Is your vehicle still in use?  
Have you authorised repairs?  
Where may the engineer inspect the vehicle?
Are you registered for V.A.T.?
What percentage can you recover? %
If you are registered for V.A.T do you authorise us to instruct repairs on your behalf?
(The V.A.T. content of the repair account is payable by you to the extent that you can recover the tax)
Circumstances of Accident
Date:
Time:
Place:
Town:
County:
Speed:
Weather Conditions:
Do you feel you (or the driver of your vehicle at the relevant time) was responsible for the accident?
If 'YES', do we have your permission to deal with the third party claim?
Did the Police attend?
If 'YES', give the officers name number and station
Name:
Police Station:
Have the police issued a notice of intended prosecution or given a verbal warning or caution?  
If 'YES', to whom and for what alleged offence?
Give details of what happen.
Particulars of Other Parties Involved and Property Damaged

Details of Persons Injured
 
Name
Address Nature of Injury
Own passengers 1:
Own passengers 2:
Own passengers 3:
Own passengers 4:
Others 1:
Others 2:
Were the passengers wearing seat belts?
Were the passengers employed by you?
I/We declare that the information given in this form is true and correct to the best of my/our knowledge/belief.
I/We understand that you may seek information from other insurers to check the answers I/we have provided.
Date:
Policyholders Signature:
Drivers Signature: