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Client Vehicle Details
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Injuries
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Additional Information
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Case Details
Case Type
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Client Status
*
Was the client a passenger in the defendants vehicle?
Yes
No
*
Please select if the client was a passenger in the defendants vehicle?
Client Details
Personal Detail
Title
*
Male
Female
*
Forename(s)
*
Surname
*
D.O.B
September 2021
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Please enter the Date of Birth
National Insurance
Either the NI Number or Reason NI Number not available must be entered
NI Number
Reason NI number not available
Address
House ID
*
Street 1/2
*
District
Town/Country
*
Postcode
Lookup Address
Contact Details
Home Tel
Work Tel
Mobile
*
Email
Invalid value
Employment
Employment Status
*
Occupation
*
Litigation Friend Details
Personal Detail
Title
*
Male
Female
*
Forename(s)
*
Surname
*
Address
House ID
*
Street 1/2
*
District
Town/Country
*
Postcode
Client Notes
Please enter required values
Confirmation
Username:
OK
Defendant Details
Personal Detail
Details unknown at present
Male
Female
*
Title
*
Forename(s)
*
Surname
*
D.O.B
September 2021
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Address
House ID
*
Street 1/2
*
District
Town/Country
*
Postcode
Lookup Address
Contact Details
Home Tel
Work Tel
Mobile
Email
Invalid value
Defendant Insurance Details
Please provide the Name, Address and contact details of the Insurance Company
*
Defendant Notes
Please enter required values
Confirmation
Username:
OK
Defendant Vehicle
Defendant's Vehicle Details
Registration
*
Make
*
Model
*
Colour
*
Defendant Vehicle Damage
Registered Keeper / Driver Details
Defendant is Registered Keeper
Personal Detail
Title
*
Male
Female
*
Forename(s)
*
Surname
*
Address
House ID
*
Street 1/2
*
District
Town/Country
*
Postcode
Defendant is Vehicle Driver
Personal Detail
Title
*
Male
Female
*
Forename(s)
*
Surname
*
Address
House ID
*
Street 1/2
*
District
Town/Country
*
Postcode
Please enter required values
Add Another Defendant?
Click on the + Icon to add another defendant to the case or click the Next Step button to continue adding the case
Accident Details
Accident Detail
Accident Date
September 2021
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Please enter the Incident Date
Accident Time
Please enter the accident time
Location
Please enter the accident location
Nearest Town
Please enter the nearest town
View Location Map
Accident Classification
Hit by party emerging from side road
Hit in the Rear
Hit whilst Parked
Concertina Collision
Accident in a Car Park
Accident on a roundabout
Accident invoving vehicles changing lanes
Other
At least one Accident Classification sholud be checked or fill other classification
Was Accident reported to the police ?
Yes
No
Was the client wearing a seatbelt ?
Yes
No
Not Supplied
* Was the client wearing a seatbelt?
Did the accident involve a bus/coach ?
Yes
No
Road Conditions
Dry
Wet
Snow
Ice
Mud
Oil
Other
At least one Road condition sholud be checked or fill other road condition
Weather Conditions
Sun
Rain
Snow
Ice
Fog
Other
At least one Weather condition sholud be checked or fill other weather conditoin
Accident Circumstances
Please enter the details of the accident
Client Vehicle
Client's Vehicle Details
Registration
*
Make
*
Model
*
Colour
*
Pre-Accident Value
No Of Occupants
No of Occupants including driver. Must be a number and at least 1
Registered Keeper / Driver Details
Client is Registered Keeper
Personal Detail
Title
*
Male
Female
*
Forename(s)
*
Surname
*
Address
House ID
*
Street 1/2
*
District
Town/Country
*
Postcode
Client is Vehicle Driver
Personal Detail
Title
*
Male
Female
*
Forename(s)
*
Surname
*
Address
House ID
*
Street 1/2
*
District
Town/Country
*
Postcode
Is the client claiming damage to their own vehicle?
Yes
No
* Is the client claiming damage to thier own vehicle?
Damage Details
Damage
Please enter the details of the Damage to the Clients Vehicle
Repair Status
*
Repair Cost
*
Is the vehicle a total loss or likely to be?
Yes
No
Don't Know
* Is the vehicle a total loss or likely to be?
Has the client been provided a vehicle by their insurer?
Yes
No
* Has the client been provided a vehicle by their insurer?
Is the claim for vehicle damage proceeding through the client's insurer?
Yes
No
* Is the claim for vehicle damage proceeding through the client's insurer?
If No, is the claim for damage proceeding through an alternative company?
Yes
No
* Is the claim for damage processing through an alternative company?
Alternative Company Details
Please provide the name, address and contact details of the Alterative Company through which the client is claiming damages
Please enter the details of the Alternative Company through which the claim for vehicle damage is proceeded
Alternative Company Case Ref
*
Do you require the defendant's insurer to organise the repairs and/or inspection?
Yes
No
* Do you require the defendant's insurer to organise the repairs and/or inspection?
Storage Location
Please provide the address where the vehicle is stored
Please enter the details of the storage location of the vehicle
Storage Contact Details
Please provide the contact details of the storage location
Please enter the details of the storage location contact
Please enter required values
Replacement vehicle
Does the client require the use of a replacement vehicle?
Yes
No
* Does the client require the use of a replacement vehicle?
Has the client been provided with the use of a replacement vehicle?
Yes
No
* Has the client been provided with the use of a replacement vehicle?
Replacement Vehicle Provider & Other Details
Vehicle Provider Details
Please provide the Name, Address and contact details of the Vehicle Provider
Please enter the details of the Replacement Vehicle Provider
Provider Ref
*
Start Date
September 2021
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*
Please enter the start date
Is the hire still on going?
Yes
No
* Is the hire still on going?
End Date
September 2021
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*
Please enter the end date
Replacement Vehicle Details
Registration
*
Make
*
Model
*
EngineSize
*
Do you require the defendant's insurer to provide the client with a replacement vehicle?
Yes
No
* Do you require the defendant's insurer to provide the client with a replacement vehicle?
Type Of Vehicle Required
*
Contact Name
*
Contact Phone
*
Please enter required values
Injuries
What type of injuries were sufferred?
Soft Tissue
Bone Injury
Whiplash
Other
Please specify type of Injuries
What type of injuries / disease were sufferred?
Respiratory
Deafness
Vibration Injury
Dermatitis
Other
Please specify type of Injuries
Details of injuries sustained
Please enter the details of the injuries
Did the client take any time off work as a result of the injury?
Yes
No
* Did the client take any time off work?
Absence Details
Is the client still absent from work?
Yes
No
* Is the client still off work?
Absent From
September 2021
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*
Please enter the date client was absent from.
Absent To
September 2021
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*
Please enter the date client was absent to.
Medical Attention
Did the client seek medical attention?
Yes
No
* Was medical attention sought?
Date Medical Attention first sought
September 2021
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*
Please enter the date medical attention first sought.
Details of GP / Hospital where Medical Attention provided
Please provide the Name and address of where the medical attention was provided Also provide any references numbers or Name of medical staff seen
Please enter the details of the GP / Hospital
Rehabilitation
Has a Medical Professional Recommended Rehabilitation therapy?
Yes
No
Medical Professional Not Seen
* Has a Medical Professional Recommended Rehabilitation therapy?
Brief details of rehabilitation treatment recommended / provided
Please enter the details of the rehabilitation recommended / provided
Are you aware of any rehabilitation needs that the claimant has?
Yes
No
* Are you aware of any rehabilitation needs that the claimant has?
Full details of rehabilitation needs
Please enter the details of the rehabilitation needs
Rehabilitation Provider Details
Please provide the Name, Address and contact details of the Rehabilitation Provider
Please enter the details of the Rehabilitation Provider
Provider Ref
*
Please enter required values
Documents
Drop file(s) here
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Additional Information
Please provide details of any witnesses/police involvement
Recommender
If you have been recommended to us, please enter their ID:
Invalid value
ID is not valid. Please correct or contact us to Add
Their Reference
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 purposes 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.
I confirm that the facts given in this case are true. Where the claimant is a child, I am the child’s parent, guardian or authorised legal representative.
*
Please read and confirm the statement of truth
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