Claim Form — PTH Claims

New Claim Form

We understand that being involved in a collision can be a difficult experience. Please complete the form below so we can assist you in obtaining the maximum compensation you deserve.

Your Details

First Name

Last Name

Date Of Birth

Full Address

Please include Post Code.

Contact Number

Country

(###)

###

####

National Insurance Number

Occupation

Employment status?

Your own Insurance Cover?

What type of claim are you reporting?

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Location Of Accident

How did the accident happen?

Date Of Current Accident

YYYY

Time Of Current Accident

Hour

Minute

Second

Any police involvement?

If Yes, police log number:

How many passengers in your vehicle?

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Any images or Videos from the accident site?

Your vehicle details:

Make & Model

Your Registration:

Number Plate

Your Insurance Company Name

Who owns the vehicle?

Is the V5C printed in your name? If No please provide the owners details.

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Vehicle At Fault Details

Make and Model

Name Of Third Party Driver

Address For Third Party Driver

Third Party Registration

Number Plate for the other vehicle

Third Party Insurance Details

Who is the fault driver insured with?

Description of the driver

Approx age of the driver? Gender type?

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Did you attend hospital or GP?

If yes, hospital or GP name and date attended

Personal injury

If you are claiming injury, what injuries have you sustained? If you are not claiming please put N/A

Will the passenger be claiming for personal injury?

If Yes, How many? If No put N/A

Agent ID

I hereby authorise my Solicitors to submit my claim on the Official Injury Claim portal on my behalf as my agent,

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Date

YYYY

Name