Online Motor Trade Claims Notification Form

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

Claim and Policyholder Details

Policy number: SM (e.g. 12345678)*

What is this? This is the 8 or 9 digit number that you will find on your policy documents.

Policy section*

On-line claim reported by*

Policyholder title

Policyholder name*

Policyholder daytime contact number*

Policyholder mobile number

Policyholder email address*

Are you the policyholder?*

Your title

First name

Last name

Your daytime contact number

Your mobile number

Your email address

Date of incident*

Day Month Year

Time of incident (HH:MM)

Broker company name*

Agent/Broker reference number*

Driver and incident details

Was the policyholder the driver?*

Driver title

Driver first name

Driver last name

Driver address 1

Driver address 2

Driver address 3

Driver town/city

Driver county

Driver's postcode, including spaces

Driver's daytime contact number

Driver's mobile number

Driver's email address

Driver's cost centre

Driver's division/depot

Driver's employee number

Location of incident

Incident description*

Speed of your vehicle (mph)

Who do you think was at fault?*

Driver date of birth

Day Month Year

Driver's occupation

Is the driver an employee of the insured?

Please state as to why this vehicle was in your possession

Has the driver been breathalysed?

Has the driver been injured?

Please enter details of any injuries to the driver

Type of driving licence

Has the Driver been involved in any motor accidents 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 enter details

Has the Driver ever been prosecuted or incurred a fixed penalty for an endorsable offence in connection with a motor vehicle in the last five years?

Please enter details

Does the Driver have any pending prosecutions?

Please enter details

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

Please enter details

Does the Driver have any disease or physical or mental infirmity, or fits of any kind that are reportable to the DVLA?

Please enter details

Vehicle details

Registration number

Vehicle make

Vehicle model

Vehicle colour

Approximate mileage

Purpose for which vehicle was being used

Registered owner and contact details

Is vehicle on finance/hire purchase?

Finance/hire purchase company name

Finance/hire purchase account number

Finance/hire purchase address 1

Finance/hire purchase address 2

Finance/hire purchase address 3

Finance/hire purchase town/city

Finance/hire purchase county

Finance/hire purchase 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

Repairer required?

Property details

Is there any property damage or loss?

Is this policyholder property or third party property?

Name of third party

Description of property

Location of property

Nature of damage or loss

Estimated cost if known

Third party details

Was anyone else involved?

Third party title

Third party full name

Third party address line 1

Third party address line 2

Third party address line 3

Third party town/city

Third party county

Third party postcode

Third party contact number

Third party email address

The name of their insurer

Insurer address 1

Insurer address 2

Insurer address 3

Insurer town/city

Insurer county

Insurer postcode

Insurer contact number

Insurer policy no.

Third party claim reference no.

Third party registration no.*

Vehicle make

Vehicle model

Vehicle colour

Any existing damage to third party vehicle?

Please give details of any previous damage to the Third Party Vehicle

Was their vehicle damaged as a result of the incident?

Please give details of any damage to third party vehicle and the surrounding area

Were they breathalysed?

Were they injured?

Please enter details of any injuries

Add another: Third party details

Pedestrians/cyclists

Were there any pedestrian/cyclists involved?

Was it a pedestrian or cyclist who was involved in the incident?*

Pedestrian/cyclist title

Pedestrian/cyclist forename

Pedestrian/cyclist surname

Pedestrian/cyclist address 1

Pedestrian/cyclist address 2

Pedestrian/cyclist address 3

Pedestrian/cyclist town/city

Pedestrian/cyclist county

Pedestrian/cyclist postcode

Pedestrian/cyclist contact number

Was the pedestrian/cyclist injured?

Please give details of any pedestrian/cyclist injury

Add another: Pedestrians/cyclists

Passengers

Were there any passengers involved?

Which vehicle was the passenger in?*

Passenger title

Passenger forename

Passenger surname

Passenger address 1

Passenger address 2

Passenger address 3

Passenger town/city

Passenger county

Passenger postcode

Passenger contact number

Was the passenger injured?

Please give details of any passenger injury

Add another: Passengers

Police details

Were the police involved?

Officer forename

Officer surname

Officer badge number

Police station

Police station telephone

Incident/crime reference

Date reported (dd/mm/yyyy)

Day Month Year

Time reported(HH:MM)

Witness details

Were there any witnesses?

Witness title

Witness forename

Witness surname

Witness address 1

Witness address 2

Witness address 3

Witness town/city

Witness county

Witness postcode

Witness contact number

Witness email

Was the witness known to the driver before the accident?

Please enter details about your prior relationship with the witness.

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?

Declaration

Please read and confirm acceptance of Allianz Terms & Conditions*

I have read the Fair Processing Notice*

Please enter this number: 9 *

Online Motor Trade Claims Notification Form

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