REFERENCE

YOUR PERSONAL DETAILS

• Title: *
• First name: *
• Surname: *
• Street address: *
• Town: *
• County: *
• Postcode: *
• Tel (work):
• Tel (home):*
• Tel (mobile):*
• E-Mail:

UNINSURED LOSSES

Please note that it is important to provide all receipts / documentation by post for the following, where available.

Have you sustained;

1. Policy Excess

Please give details of excess

2. Personal Injury

Please give details of injuries sustained. Please also confirm whether you attended hospital / GP.

3. Hire Charges

Have you been contacted by ANY Hire Company for example Drive Assist, Accident Exchange or AI Claims: if so please advise the company's name and provide their reference number:

4. Loss of earnings

Please give details

5. Storage and recovery charges

Please give details

6. Loss of use

Please give details of the period of time that you were unable to use your vehicle e.g. undrivable, repairs

7. Any other losses

Please give details

DESCRIPTION OF ACCIDENT

Please provide a brief statement as to the circumstances of the accident

If the matter proceeds, can you confirm that you will/the driver will attend court to give evidence? *

YOUR SOLICITORS

If solicitors are acting on your behalf please give their details including reference:

• Reference number:
• First name:
• Surname:
• Street address:
• Town:
• County:
• Country:
• Tel (work):
• Tel (home):
• E-Mail:
• Please write today's date here: *

Please note that depending on the answers given above, you may be required to sign a statement at a later date.