Insurance Claim Online Form - Draft Copy

Section 1
Data Protection Fair Processing Statement: The information which you provide on this form will be held by Devon County Council and may be shared with the Council’s contractors, solicitors and insurance company if necessary. Please read our privacy notice for more information relating to how we handle your data.
Fraudulent claims will be investigated.
I am aware by submitting this form I may be contacted for further information if my claim progresses to the next stage. Further information will include, MOT Certificate, Insurance, Service History, however the information we request will depend on the type of claim. A payment will not be made until this further information is received.*
- I agree

Section 2
Claim Type:*
- Vehicle Damage
- Personal Injury
- Property Damage
Please provide evidence that the vehicle is legally taxed*
Please attach a screenshot from - Vehicle Tax

Section 3
Have you reported the defect/issue?*
- Yes
- No
- The defect/issue has been repaired
If the incident date was longer than 6 weeks ago and the defect/issue has been repaired, please continue with the form without reporting the issue to reduce the likelihood of an unnecessary site visit.
Reference Number*
Please explain when you were aware that the defect/issue was repaired*
Please report the issue/defect here - Report a Problem Page. Once you have reported the issue/defect please return to the claim form with the reference number

Section 4 - Personal Details
Name*
Title First Last
Address*
Street Address Town Post Code
Email

The inclusion of an email address will enable us to process your claim more quickly
Phone*

Section 5 - Description of the Incident
Exact Date of the Incident*
Date Format: DD slash MM slash YYYY
Time of the Incident*

: HH

MM
Please provide as much information as possible as to the location of the incident (road name, adjacent landmarks),*
Please provide a map, highlighting the exact location of the incident*
If you are unable to identify the location, we will be unable to progress your claim further. We cannot accept claims for wear and tear of a vehicle over a prolonged period, Devon County Council have a strict inspection routine in place which allows us to record and repair defects which meet our safety criteria
Describe the incident (exactly what happened and your opinion of the cause of the incident)*

Section 6
Damage suffered and any further details of damage*
Your Vehicle Registration Number*
Cost of repair*
Note: We are unable to accept quotations. A payment will not be made on a quotation, a receipt evidencing repair costs will need to be provided.
Please attach copies of your receipts for repair*
Description of Injuries Sustained*
Did you attend Hospital?*
- Yes
- No
Hospital Name*
Describe Damage*
Cost of Damage*
Please Attach Copies of your Receipts

Section 7 - Declaration
I believe that the statements of fact contained in this document are true, to the best of my knowledge and belief, and am aware this is a legal document*
- I agree
Date Form Signed
Date Format: MM slash DD slash YYYY
CAPTCHA

Insurance Claim Online Form – Draft Copy