Vehicle damage claim form - Roads and transport

Section 1 – data protection

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.

Section 2 – reporting the issue

Has the issue/defect been reported to Devon County Council?*

Yes

The defect/issue has been repaired

Please provide the reference number for the report*

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

Please explain when you were aware that the defect/issue was repaired*

Section 3 – Pictures

Please provide photos showing the defect (if safe to obtain)

Drop files here or

Accepted file types: jpg, gif, png, Max. file size: 2 MB.

This will help ensure that we are investigating the correct defect and location.

Please provide photo(s) of the damage

Drop files here or

Accepted file types: jpg, gif, png, Max. file size: 2 MB.

It is important that we receive as much information as possible. Any photographic evidence will assist us when reviewing your claim.

Section 4 – Personal details

Name*

First Last

Address*

Street Address Address Line 2 Town Post Code

Email

The inclusion of an email address will enable us to process your claim quicker

Phone*

Section 5 – Description of the incident

Please provide the exact date of the incident*

Please detail the time of the incident*

:

Please provide as much information as possible as to the location of the incident (road name, adjacent landmarks), this information will assist us when investigating your claim*

Please provide a map, highlighting the exact location of the incident*

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

You must provide a map highlighting the correct location for us to accurately assess your claim

Describe the incident (exactly what happened and your opinion of the cause of the incident). Please provide as much information as possible*

Section 6 – details of damage

Your vehicle registration number*

Please detail the damage which has been caused to your vehicle specify which tyre(s)*

Cost of repair*

Please attach copies of your receipts for repair*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

Please note that 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.

Section 7 – required documentation

Please provide evidence that the vehicle is legally taxed*

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

It is important to prove that your vehicle is legally roadworthy. You can attach a screenshot from the Government Website – Check your Vehicle Tax

Please provide a copy of the Vehicle Registration (V5) document (you must be the vehicle owner)*

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

If the vehicle is a hire car, please provide a copy of the rental/lease agreement. If the vehicle is a company car, please provide evidence of this.

Please provide your Insurance document (valid at the time of the incident)*

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

Please provide your MOT Test certificate (valid at the time of the incident)

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

Section 8 – additional documentation

Please provide a copy of your last service (if available)

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

Please provide supporting evidence for the age of the vehicles tyres (if available)

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

Section 9 – Declaration

I understand that any suspected fraudulent claims will be vigorously investigated and where fraud is proven Devon County Council will seek to recover costs which could be pursued through the criminal or civil courts.

I confirm that I am aware that this is a legal document and confirm that the statements contained in this document are true and matter of fact, to the best of my knowledge and believe.*

I agree

Date form signed*

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