Motor Claims Notification Form

You will be contacted by a claims handler in due course, who will advise you of the claims reference number and any further documentation that is required in support of your claim.

Please note that fields marked with asterisk (*) are mandatory.

Claim & Policyholder Details

Policy Number (prefix)*

Policy Number*

Are you the?

Date of Incident*

Day Month Year

Time of Incident(Hour)

Time of Incident(Minute)

Location of Incident

Please provide the incident location details

Your Title *

Your Forename *

Your Surname*

Your Telephone*

Your Telephone Number*

Your Email Address *

Is the policyholder VAT registered?

Driver & Incident Details

Driver Title*

Driver Forename *

Driver Surname *

Driver Address 1*

Driver Address 2

Driver Address 3

City *

County*

Driver Postcode, including spaces*

Relationship of Driver to Policyholder

Driver Telephone *

Driver Telephone Number*

Driver/Policyholder Email Address

Incident Description*

Speed of Vehicle (mph)*

Who do you consider responsible? *

Drivers Date of Birth *

Day Month Year

Driver Occupation *

Has driver been breathalysed

Driver Injury

Please enter details of any injuries to the driver

Type of Licence

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?

Please give details

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?

Please give details

Has the driver ever had a Motor policy cancelled, declined, declared void refused renewal or asked to bear special terms or conditions?

Please give details

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?

Please give details

Vehicle Details

Registration Number*

Manufacturer *

Model *

Colour

Approximate Mileage

Purpose for which vehicle was being
used*

Registered owner and contact details *

Is Vehicle on Finance/HP?

Finance/HP Company Name

Finance/HP Account Number

Finance Company Address 1

Finance Company Address 2

Finance Company Address 3

Finance Company City

Finance Company County

Finance Company Postcode, including spaces

Any previous damage to vehicle?

Please give details of any previous damage to the vehicle

Vehicle damaged as a result of incident *

Damage to vehicle including area

Is vehicle driveable?

Current Vehicle Location*

Repairers required?

Does vehicle qualify for recovery of VAT?

Third Party Details (if applicable)

Please select from the following options (Third Party Details)

Third Party Title

Third Party Forename

Third Party Surname

Third Party Address 1

Third Party Address 2

Third Party Address 3

Third Party City

Third Party County

Third Party Postcode, including spaces

Third Party Telephone Number (Home)

Third Party Telephone Number (Mobile)

Third Party Incident Description

Third Party Insurer Name

Third Party Insurer Address 1

Third Party Insurer Address 2

Third Party Insurer Address 3

Third Party Insurer City

Third Party Insurer County

Third Party Insurer Postcode, including spaces

Third Party Insurer Telephone*

Third Party Insurer Policy No.*

Third Party Claim Reference No.

Manufacturer

Model

Colour *

If applicable please give details of any previous damage to the third party vehicle

If applicable please give details of any damage to third party vehicle and the surrounding area

If applicable please enter details of any third party injuries

Add another: Third Party Details (if applicable)

Passengers

Please select from the following options (Passengers)

Which Vehicle

Passenger Gender

Passenger Title

PassengerForename

Passenger Surname

Passenger Address 1

Passenger Address 2

Passenger Address 3

Passenger City

Passenger County

Passenger Postcode, including spaces

Passenger Telephone (Home)

Passenger Telephone (Mobile)

If applicable please give details of any Passenger Injury

Add another: Passengers

Police Details

Please select from the following options(Police Details)

Officer Title

Officer Forename

Officer Surname

Officer Badge Number

Police Station

Police Station Telephone

Incident/Crime Reference

Date Reported

Day Month Year

Time Reported(Hour)

Time Reported(Minute)

Witness Details

Please select from the following options (Witness Details)

Witness Gender

Witness Title

Witness Surname

Witness Address 1

Witness Address 2

Witness Address 3

Witness City

Witness County

Witness Postcode, including spaces

Witness Telephone (Home)

Witness Telephone (Mobile)

If applicable please enter details about the witness if they have been known to you before

Add another: Witness Details

Status Details

Is this form for information only (No repairs to either vehicle)?

Please enter details if there are no repairs to either vehicle required

Any Other Information (Relevant to Claim)

Have you received any correspondence from a third party on the Claim?

Please enter details about the correspondence that you have received from a third party about the claim

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, unanswered, all correspondence you or the driver receive from others involved in the incident to your insurance advisor or your Allianz office.

Terms & Conditions

Please read and confirm acceptance of Allianz Terms & Conditions*

I accept Allianz terms and conditions

Motor Claims Notification Form

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