MAKE A CLAIM

Fleet Insurance claim form

Please complete this form fully. It is a condition of your policy to report all incidents as soon as possible even if you do not intend to make a claim.

Any correspondence received in connection with the incident must be submitted immediately.

PLEASE NOTE. Questions marked * must be provided otherwise we will not be able to process the claim.

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COMPANY DETAILS

Company name:

Policy number:

Company address:

Best point of contact on the claim:

Telephone number:

Email address:

Is the policyholder VAT registered?

Yes

Is VAT recoverable?

Yes

DRIVER IN CHARGE OF VEHICLE (immediately before the accident)

Driver’s name:*

Driver’s address:*

Driver’s date of birth:*

Date of first full licence:*

If not the policyholder, did the driver have the policyholders permission to drive?:*

Yes

Does the driver have any medical conditions disclosed to the DVLA?:*

Yes

Details of the medical conditions:*

Does the driver have any convictions on their licence?:*

Yes

ACCIDENT DETAILS

Date:

Time:

Location:

Road conditions:

Weather conditions:

Estimated speed:

Was your driver responsible?:*

Yes

Accident description:

Accident photos:

UPLOAD

POLICYHOLDER VEHICLE

Make:

Model:

Colour:

Name of hire/lease company:

Description of damage:

Is the vehicle roadworthy?:

Yes

REPAIRS

Would you like to utilise one of our approved repairers? *:

Yes

Name:*

Address:*

Telephone number:

Is the vehicle at the repairer’s premises?:*

Yes

PURPOSE

Purpose for which vehicle was being used?:

Nature of goods being carried? (if any):

Number of persons being carried? (Including the driver):

THIRD PARTY DETAILS

Was there a third party involved?:

Yes

PASSENGERS IN THE POLICY HOLDERS VEHICLE

Were there any passengers in the policy holder vehicle?:

Yes

INDEPENDENT WITNESSES

Were there any independent witnesses?:

Yes

POLICE DETAILS

Were the police involved?:

Yes

Police officer’s name:

Police officer’s number:

Police station’s address:

Police reference:

Is the vehicle at the repairer’s premises?:*

Yes

ADDITIONAL INFORMATION

Please upload any photos you’d like to include:

Upload

Is there anything else you’d like to include?:

Grove & Dean Insurance Brokers is a trading name of Grove & Dean Ltd, an independent insurance intermediary who are authorised and regulated by the Financial Conduct Authority (FCA), registration number 307002. Grove & Dean Ltd, registered in England and Wales, company number 1167043.