Commercial Vehicles
 
Incident Report Form
Please tell us where you heard about Platinum Assist:
Who is your broker?
INCIDENT REPORT FORM
If you intend to deal with any vehicle/property damage caused, without claiming under your policy and no personal injury is involved.
Please tick the box to show that details given are for information purposes only.
Section 1: Your details
* Please complete in all circumstances

Policy Number
Cover
Full Name(s)
Sex
Date of birth
/ /
Company Name
Address
Postcode
Occupation
Employer
Your Email
Telephone:
Day
Evening
Mobile
Are you VAT registered?
If "YES" please provide VAT registration number
Section 2: Your Vehicle
* Please complete in all circumstances

Make/Model
c.c.
Reg. No.
Number of seats
Value
Mileage
Date of purchase
Year of manufacture
G.V.W.
Colour
Has the vehicle been modified in any way from manufacturer's original specification?
If "YES" please give details

Is the vehicle subject to a HP Agreement or Leasing Contract?
If "YES", Name and Addressing of HP/Leasing Company and Account Number

Are you the owner of the vehicle?
If "NO" please give name and address of owner

Is the owner VAT registered?
Section 3: Driver or Person Last in Charge of The Vehicle
* Please complete in all circumstances

Full Name(s)
Sex
Date of birth
/ /
Address
Postcode
Occupation
Employer
How long employed
Telephone:
Day
Evening
Mobile
Any physical or mental defects or impairment of sight / hearing?
If Yes please give full details.

Has the driver had any accidents, claims or losses in the past five years?
If Yes please give full details including date of incident, circumstances, costs and outcome.

Has the driver had any motoring convictions?
If "YES" give full details including the date of offence, date of conviction, conviction code, penalty points and amount of fine imposed

Type of driving licence held
Date test passed
/ /
Driving Licence Number
Is the driver the main user of the vehicle?
If "NO" please give name, age, address and occupation of main user.

What was the purpose of the journey?

Section 4: Your Vehicle Damage
* Only complete if your vehicle has been damaged

Please describe the damage to your vehicle

Is the vehicle mobile/still in use?
If "NO" where is the vehicle?


Address
Telephone Number
If appropriate, may the vehicle be moved to an Insurer's approved repairer?
Have you instructed a garage to commence repairs?
If "YES"


Name
Address
Telephone Number
Section 5: Theft or Attempted Theft Details
* Only complete if your vehicle has been stolen or there was attempted theft or theft from your vehicle.

Was the vehicle left unattended?
If "YES", under what circumstances was the vehicle left unattended?

Did you remove the ignition key?
If "YES", who has the keys now?

Were the doors/boot locked?
Was a security device in operation?
If "YES", state type including make/model

Was the vehicle in a garage at the time of the incident?
Please note it may be necessary for you to provide a statement of facts to your insurers or their appointed representatives in relation to this incident.

Section 6: Incident Details
* Please complete in all circumstances.

Date of incident
/ /
Time of incident
Where exactly did the incident occur? (street, town, postcode etc)

Was the incident report to the Police?
If "YES", state Address of Police Station, Police Officer's name and number, and reference number allocated to the incident.

Has any person been advised they may be prosecuted as a result of this incident?
If "YES", give full details.

Who do you consider was to blame for the incident? (Please tick one box)

Self Other Person Both Persons
Once you have been allocated a claim reference number, please provide a sketch of the incident scene, including all vehicles involved, direction of travel and any road signs/markings. Any photographs you have of the incident scene would be useful.

Please describe in as much detail as possible, the full accident circumstances.

Section 7: Other Motor Vehicles or Property
If you receive any correspondence or telephone calls from representatives acting for the third party, it is essential that details of any offers of assistance are reported to us immediately. Failure to do so may result in you being liable for the costs of any hire vehicle even if the accident was not your fault.

* Only complete if other motor vehicles or property have been damaged or involved in the incident

Third Party 1
Owner/Drivers name
Address
Telephone
Make & Registration Number of vehicle/damage to property:

Damage
Insurers:(Name, address & Policy Number)

Third Party 2
Owner/Drivers name
Address
Telephone
Make & Registration Number of vehicle/damage to property:

Damage
Insurers:(Name, address & Policy Number)

Section 8: Injured Persons
* Only complete if persons have been injured.

Third Party 1
Name
Address
Injuries sustained
Where all injured parties wearing seatbelts
If a passenger, state in which vehicle

Third Party 2
Name
Address
Injuries sustained
Where all injured parties wearing seatbelts
If a passenger, state in which vehicle

Third Party 3
Name
Address
Injuries sustained
Where all injured parties wearing seatbelts
If a passenger, state in which vehicle

Third Party 4
Name
Address
Injuries sustained
Where all injured parties wearing seatbelts
If a passenger, state in which vehicle

Please describe the injuries you sustained and the treatment provided thus far. In particular:
Did you hit your head at all?
Do you have any headaches, neck or back pain?
If yes, which, how frequent and how severe?

Please indicate whether you have had any other symptoms such as loss of sleep, nausea or sickness.
Are you fully recovered from all the effects of the accident?
Details of your physical conditions and any ailments or illnesses in the period of six months immediately prior to the accident.

Were you wearing a seat belt?
Please provide full details including, names, addresses, hospital numbers of all Doctors and hospitals providing treatment and include details of your GP Please also specify whether you have attended your GP in relation to the injury.

Please confirm your National Insurance Number
Please confirm if you are in receipt of any benefits. If so,
(a) What type of benefit i.e. Incapacity, Income Support
(b) Is this benefit means tested?
Please give the name and address of your employer.
Name
Address
Have you had any time off work? If so, how long, and provide details of any loss of earnings or income arising from the accident. Please also indicate whether you are now back, at work.
Section 9: Witnesses to the Incident
* Please complete in all circumstances where there were witnesses to the incident.

Witness 1
Name
Address
Telephone
If a vehicle passenger, state in which vehicle

Witness 2
Name
Address
Telephone
If a vehicle passenger, state in which vehicle

Witness 3
Name
Address
Telephone
If a vehicle passenger, state in which vehicle

Witness 4
Name
Address
Telephone
If a vehicle passenger, state in which vehicle

Section 10: Data Protection Act 1998
* Please note

Insurers pass information to the Claims and Underwriting Exchange Register, run by Insurance Data Base Services Limited (IDS Ltd) and the Motor Insurance Anti-fraud and Theft Register, run by the Association of British Insurers (ABI). The aim is to help Insurers check information provided and also to prevent fraudulent claims. Under the conditions of your policy you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. Insurers will pass information relating to this incident to the registers.

All claims are screened using various fraud databases and registers. the aim is to verify information and to prevent fraudulent claims.

In dealing with this claim, we will be passing information relating to this incident to the appropriate databases and registers, as well as searching those databases and registers.

Fraudulent claims are always vigorously pursued.

Section 11: Declaration
* Please note

I/We declare that the above statements are true and correct to the best of my/our knowledge and belief. I/We have not withheld from the insurer any information without my/our knowledge connected with this claim. I/We agreed to provide the insurer with any further information or documentation as may be reasonably required. I/We understand that the insurer does not admit liability by the issue of this form.

I/We understand that you may seek information from other insurers to check the answers I/we have provided. I/We confirm that I/we have no objection to my/our insurers obtaining any information they require from the DVLA in connection with my/our driving licence(s).

I/We understand that my/our insurer may ask IDSL or ABI for information they have received from other insurers to check the answers I/we have provided.

If you receive any correspondence or telephone calls from representatives acting for the third party, it is essential that details of any offers of assistance are reported to us immediately. Failure to do so may result in you being liable for the costs of any hire vehicle even if the accident was not your fault.

FRAUD WARNING: The submission of a bogus or exaggerated claim, either in whole or in part, or any false documentation or statement in support of a claim, may invalidate the whole claim and lead to your policy being declared void.

Accept the Terms


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Platinum Assist Limited is authorised and regulated by the Financial Conduct Authority.
Platinum Assist Limited Registered Address: Second Floor Cardiff House Tilling Rd London NW2 1LJ Company No. 6451749 Registered in England and Wales.