Claim Notification Form - Liability & Motor

Claim Notification Form - Liability & Motor
For information about how we will handle your personal information, please see our privacy policy.

Claimant information

This should be the information of the person that has suffered the injury or damage to their property.
Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Postcode
Telephone number*
Email*
example@example.com
National Insurance Number*
Date of Birth*

DayMonthYear
Occupation*
If you have an impairment that may affect your communication with us, please describe your impairment(s) and the support you require.

Motor
Please state the registration number of the vehicle you hold at fault.*
If known, please provide the name of the driver.

First NameLast Name
If the incident was reported to the police, please provide the crime reference number and the police station it was reported to?
What loss have you suffered?*
Please describe the exact damage to your property, providing an approximate cost of the replacement/repair and advise on roughly how old the item/vehicle was at the time of the incident. Also, for property damage to a vehicle, please include the make, model and colour. If you have suffered any injury, please describe in full below.
If relevant, please state your vehicle registration number.
If relevant, please state your vehicle's colour, make and model.
Did you witness the incident?*

YesNo
If there were additional witnesses, please provide their name/s and contact details.

Liability
For damage to your property, please describe the exact of the damage and how long it has been present for. Please also providing an approximate cost of the replacement/repair and advise on roughly how old the item was at the time of the incident.

For damage to a vehicle, please include the make, model and colour.

For injuries, please be specific and reference the part of the body affected (e.g. sprained right ankle)
What damage or injury have you suffered?*
If your claim is for property damage, are you the sole owner of the property in question?

YesNo
If you are not the sole owner, please provide further details below.
If your claim includes injury, please state if you had to attend hospital due to the incident and, if so, please give the address of the hospital(s) and/or GP Surgery you attended.*
Why do you believe the party you hold at fault is legally liable for your loss?
If your incident is related to a road defect, can you provide an image of the defect or pothole.

Cancelof
Please provide any photographs or other evidence to support your claim

Cancelof

Statement of Truth

In completing this form, I understand that I am making a legal liability claim for compensation. The facts that I have provided in this form are true to the best of my knowledge.

Please note that once this document has been submitted to the London Borough of Sutton it is disclosable in court and may be shared according to the data protection notice at the start of the form.

To sign that you agree with this statement, please type your full name into the signature box. Where the claimant is a child the signature below will be the child’s parent or guardian (litigation friend).
Signature*
Would you like someone else to handle this claim on your behalf? This can include a friend, relative or professional.

YesNo

Representative Details

You have indicated that you wish for someone else to handle this claim on your behalf.

By filling in this section of the form you are agreeing to the above named representative to deal with your claim on your behalf. Any correspondence will be sent to them.
Representative name*

First NameLast Name
Representative home address*

Street Address

Street Address Line 2

CityCounty

Postcode
Representative telephone number*
Representative email address*
example@example.com

Claimant information