Claim Notification

Policy Holder	This should be the name of your Employer if you were driving a Company vehicle or under Insurance arranged by your Employer
Address of Policy Holder	If working from a store/depot the address you work out of
Name of Driver
Address of Driver
Drivers Phone Number
Drivers Date of Birth (DD/MM/YY)
Type of Licence Held
Date test passed for vehicle driven (DD/MM/YY)
Use of Vehicle at time of accident
If use of vehicle "other" please specify
Any driving convictions
If yes then details of convictions (Date, Offence Code, Number of points, Fine, Ban)
Any Disabilites
If yes the details of disabilities and if DVLA notified (if required)
Make and model of your vehicle
Registration number of your vehicle
Damage to insured vehicle
Are you at fault for the accident
Date of accident
Location of incident
Description of accident
Police Involvment/details
Speed of vehicle
Third Party Details
Name
Address
Telephone
Was the third party injured?

Name, address and phone number for any other vehicle/property involved
Make, model and registration number of other vehicle
Nature of damage to other vehicle
Approximate speed of other vehicle
Details of passengers in the other vehicle including gender and seating position or state none
Please give full details of any additional vehicles involved in the accident
You can send a copy of this form to up to two email addresses

If you have any images, diagram or documentation to support your claim, please upload your files below

Upload images (Image File Types supported - JPG, GIF, PNG)

Once you are happy with the details on this page please press the submit button

If you have any question or are unsure how to complete this form, please contact our claims department on 020 8568 2021

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Barnett and Barnett Limited is authorised and regulated by the Financial Services Authority (FSA no.306088) and are members of BIBA. Registered in England & Wales. Number 04024377. Registered Office:650 London Road, Isleworth, Middlesex, TW7 4EG
Barnett and Barnett Financial Services Limited is authorised and regulated by the Financial Services Authority (FSA no.118681) and are members of AIFA. Registered in England & Wales. Number 01856766. Registered Office: 650 London Road, Isleworth, Middlesex TW7 4EG