Commercial Vehicles
 
Legal Liabilities Form
Who is your broker?
This report is made in a bona fide belief that litigation may ensue and to enable the Employer's Representatives, Solicitors and/or Agents to conduct and advise in relation to such litigation.
Policy Holder (required)
Name of insured
Policy Number
Your Email
Address
Postcode
Business
Tel. No
Are you registered under VAT regulations?
If Yes please give details
Details of Accident (required)
Date
Time
Place
Full details and description of the accident
Name of person who caused the accident
Address
Employers
Has any accident due to same cause happened before? If so, give details
If accident involved sub contractors or any of their employers, give sub contractors
Name
Address
Employers
Public Liability Insurers
Policy Numbers
What was the extent of injury or damage sustained by the Third Party?
If the claim is in respect of loss of or damage to property belonging to the claimant, state the approximate value of the loss or damage
To whom was a complaint first made and by whom?
Give name and address of Third Party and if possible, occupation and insurers
Witnesses
Give names and addresses of any Witnesses, and state whether or not they are in your employment
Have you received any claim? If so, from whom?
Was the matter reported to the Police? If so, give Officer's No. and Station
Was the matter reported to the Police? If so, give Officer's No. and Station
Data Protection Notification
We may use personal and business details you give us, or which are supplied by third parties, to consider your claim, to search the files of credit reference agencies who may keep a record of the search, to carry out such financial and other enquiries as we consider necessary to evaluate the claim and assist in making a decision regarding the claim, and the compliance business reviews. We may also share these with other insurance organisations and selected other parties to handle claims and prevent fraud. Personal details may be transferred to countries outside the EU. They will at all times be held securely and handled with the utmost care in accordance with all principles of UK Law. We will store such personal derails on computer but will not keep them for longer than necessary. Under terms of the Data Protection Act 1998, individuals are entitled to a copy of all the information we hold about them.

VERY IMPORTANT - FRAUDULENT AND EXAGGERATED CLAIMS Deliberately exaggerated claims could invalidate your policy cover. Insurance fraud is a crime and liable to prosecution.
 The above answers to our questions will be the basis of consideration of your claim. You must ensure that all information is true and correct to the best of your knowledge and belief, and that all material facts have been disclosed. A material fact is one that is likely to influence us in the assessment or acceptance of this claim, or one that is likely to influence our consideration of cover under the terms of your policy. If you are in any doubt as to whether a fact is material, you must disclose it.

FAILURE TO DO THIS MAY MEAN THAT YOUR POLICY BECOMES INVALID AND A CLAIM PAYMENT WLL NOT BE MADE.
I/We declare the foregoing particulars to be correct according to our information and belief. I/we understand that you may seek information from other insurers to check the answers I/We have provided. This report is made in the bona fide belief that litigation may ensue and to enable solicitors and/or agents to conduct such litigation and advice in relation thereto.
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©Platinum Assist Limited 2009
Platinum Assist Limited is authorised and regulated by the Financial Services Authority.
Platinum Assist Limited Registered Address: Second Floor Cardiff House Tilling Rd London NW2 1LJ Company No. 6451749 Registered in England and Wales.