Motor Vehicle Accident Claim Form

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Important - any claim request submitted must be authorised by the Hirer.

If you wish to notify R&SAM of a new claim then you can either telephone on 0500 474747 or complete the form below.

Following the submission of this form we will need to contact you to complete the registration of your claim.

Before proceeding to submit any personal details please read the Privacy Policy included on this website.

Please make sure you complete all details marked *

Call Back

*Please select the most appropriate time to contact you :

DD/MM/YYYY

HH:MM

Motor Vehicle Accident Claim Form

The Person Completing this Form:

*Loss reported by :

*Title :

*First Name :

*Surname :

Personal Details of Hirer

*Title :

*First Names :

*Surname :

*Postcode :

*Address Line 1 :

Address Line 2 :

Address Line 3 :

Address Line 4 :

Address Line 5 :

*DOB :

DD/MM/YYYY

Policy Information

*Policy Number : RKX1 or RKX7/RMO

(This can be found on your Certificate of Motor Insurance)

Hirer's Telephone Number (inc STD)

*Home No :

Mobile No :

Vehicle Details

*Registration No :

*Make & Model :
e.g. Renault Clio

*Was the vehicle being used on the Hirer's order or with permission :

For what purpose was the vehicle being used :

Details of Driver or last person in charge of vehicle

*Was the Hirer the Driver? :

*Title :
*First Names :		*Surname :
		*Postcode :
		*Address Line 1 :
		Address Line 2 :
		Address Line 3 :
		Address Line 4 :
		Address Line 5 :
	*DOB :	DD/MM/YYYY
*Type of License :
Date Passed Driving Test :		DD/MM/YYYY
Driver's Home No :		Driver's Mobile No :

If you have had any accidents or convictions within the last 5 years we will require full details when we contact you to discuss this claim.

Circumstances of Accident

*Date of Accident :

DD/MM/YYYY

Time of Accident :

e.g. 14:15

Place of Accident including road & town :

Was the driver and all passengers wearing seat-belts? :

*Details of accident :

Damage to Vehicle

*Where is the damage to your vehicle?
(please click to highlight the corresponding number on the diagram below to indicate the area of damage to the vehicle shown from above - double click to remove highlight).

*Description of damage? :

Our Recommended Repairer Scheme offers the advantage of guaranteed repairs and a free courtesy car.

Is your vehicle still driveable? :

Are you happy to use a recommended repairer? :

Third Party Details

*Was there another party involved in the accident?

Title :

Third Party First Names :

Third Party Surname :

Third Party Postcode :

Address Line 1 :

Address Line 2 :

Address Line 3 :

Address Line 4 :

Address Line 5 :

Third Party Telephone No :

Registration No :

Make & Model :

Insurance Company's Name, Address, Telephone No & Policy No :

Damage to other vehicle, if any :

*Was there another party involved in the accident?

Title :
Third Party First Names :		Third Party Surname :
		Third Party Postcode :
		Address Line 1 :
		Address Line 2 :
		Address Line 3 :
		Address Line 4 :
		Address Line 5 :
		Third Party Telephone No :
Registration No :
Make & Model :
Insurance Companies Name, Address & Policy No :
Damage to other vehicle, if any :

Details of Injured Persons

*Was there anyone injured in accident? :

Witnesses

*Were there any witnesses to accident? :

Uninsured Losses

If the accident was the fault of another party, then we will aim to recover your uninsured losses from the person who caused the accident. These will include your policy excess, compensation for injury or out of pocket expenses. We will discuss this option further with you when we make contact.

Important Notice

In order to prevent and detect fraud we may at any time:
Share information about you with other organisations and public bodies including the Police

Check and/or file your details with fraud prevention agencies and databases, and if you give us false or inaccurate information and we suspect fraud, we will record this.

We can supply on request further details of the databases we access or contribute to.