YOUR DETAILS







    Are you claiming vehicle damage?

    NoYes

    Level of Cover

    ComprehensiveThird Party Fire & TheftThird Party OnlyOther

    ACCIDENT DETAILS

    Accident Date



    Weather Conditions

    SunRainSnowIceFogOther

    Road Conditions

    DryWetSnowIceMudOilOther

    At the time of the accident, were you:

    the driverthe owner of the vehicle but not drivinga passenger in a vehicle owned by someone elsea pedestriana cyclista motorcyclistOther

    Were you wearing a seatbelt?

    YesNo


    If owner not driver, please confirm




    Accident Circumstances:

    Claimant Vehicle hit by party emerging from side roadClaimant vehicle hit in the rearClaimant vehicle hit whilst parkedAccident in car parkAccident on a roundaboutAccident involved vehicles changing lanesConcertina CollisionOther

    Reported to the Police?

    YesNoNot Known



    DEFENDANT DETAILS







    INJURY DETAILS

    Injuries Sustained

    Soft TissueBonyWhiplash

    Time off Work?

    YesNoNot Applicable

    Still Off Work?

    YesNoNot Applicable

    Did you seek medical attention?

    YesNo

    Did you attend Hospital?

    YesNo

    OTHER INFORMATION

    Please provide any other relevant information

    How did you hear about Bank View Solicitors?

    Please Attach Your Identification, Proof of Address , Sketches of Accident or Any Other Relevant Documents Below:

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    STATEMENT OF TRUTH

    Your personal information will only be disclosed to third parties, where we are obliged or permitted by law to do so. This includes use for the purpose of claims administration as well as disclosure to third-party managed databases used to help prevent fraud, and to regulatory bodies for the purposes of monitoring and/or enforcing our compliance with any regulatory rules/codes.

    Where our services have been recommended to you, do you consent to us liaising with the introducer to progress your claim? This may include sending written communication to them as well as discussing your claim over the phone. This consent can be withdrawn at any time by you.

    Yes, I give my consentNo, I do not give my consent

    Please enter your full name

    By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this claim form are true and accurate, to the best of your knowledge.