Personal Injury & Vehicle
Damage Claim form
Accident Type
*
Select an option
Road traffic accident
Incident at work
Medical negligence
Tripping and falling
Recovery & Storage
*
Select an option
Recovery only
Storage only
Recovery & Storage
Full Name
*
Date of birth
*
Contact Number
*
Email Address
*
Home Address
*
Incident Date
*
Time
*
AM
PM
Location
*
Weather Condition
*
Select an option
Sun
Rain
Snow
Ice
Fog
Fine
Other
Road Condition
*
Select an option
Dry
Wet
Snow
Ice
Mud
Oil
Fine
Other
Circumstances
*
Select an option
Claimant vehicles hit by party emerging from side road
Claimant hit in the rear
Claimant vehicle hit whilst parked
Accident in a car park
Accident on a roundabout
Accident involving vehicle changing lanes
Other
Damage On Your Vehicle
*
Select an option
Rear damage
Front damage
Passenger side damage
Driver side damage
Rear bumper
Front bonnet
Front bumper
Passengers side doors
Driver side doors
Passenger side tiers
Driver side tires
Passenger side rear quarter panel
Driver side rear quarter panel
Front passenger side quarter panel & bumper
Front driver side quarter panel & bumper
How Many PPL In Your Vehicle?
*
Select an option
0
1
2
3
4
5
6
7
8
9
10
If Police Involved Give Details
*
Select an option
Yes
No
Vehicle Make & Model
*
Vehicle Registration
*
Insurance Name
*
Type Of Cover
*
Select an option
Fully compressive
Third party, Fire & Theft
Third party only
Instruct Engineer
*
Select an option
Yes
No
If Yes Vehicle Location
*
Select an option
At home address
At storage place
Occupation
*
NI Number
*
Images/Videos Taken At The Seen Of Accident
*
Select an option
Photography evidence attached
No images & videos attached
CCTV footage available
Witness Details If Any
*
Select an option
Yes
No
TP/ Fault Driver: Details
Select an option
Full Name
Address
Contact number
Total number of occupants in the vehicle
Vehicle make and model
Vehicle registration number
Insurance name and policy number
Have you been Injured?
*
Select an option
Yes
No
Accident Circumstance Details
*
Indicate Injuries
*
Select an option
Whiplash/Neck, back & shoulder
Whiplash/Neck, back & both shoulders
Neck
Right shoulder
Left shoulder
Upper back
Lower back
Right arm
Left arm
Right leg
Left leg
Head injury
Right hand
Left hand
Specify Injuries
*
Psychological Symptoms
*
Select an option
Mood changes
Thinking problems
Sleep changes
Appetite changes
Social withdrawal
Substance abuse
Suicidal thought
Excessive fear or worry
Feeling guilty or worthless
Delusions or hallucinations
Lack of insight
Feeling overwhelmed or helpless
Feeling frustrated or uncertain
Earringing Symptoms
*
Select an option
Ringing, buzzing, hissing, chirping, or whistling in one or both ears
Sounds that vary in loudness and come and go
Sounds that are more noticeable in quiet environments, like when trying to sleep
Common types of headaches
*
Select an option
Tension headaches
Whiplash headaches
Post-traumatic headaches
Migraines
Confusion or memory problems
*
Select an option
Nausea and vomiting
Vision changes
Ringing in the ears with head trauma
Difficulty concentrating
Sensitivity to light and sound
Date Attended GP/Hospital
*
GP/Hospital Details
*
Taken Time Off Work?
*
Do you wish to Claim for Loss of Earnings?
Select an option
Yes
No
Signature
Please sign here
Your browser does not support e-Signature field.
Full Name
*
Date:
*
By submitting this form, I agree to the
(Privacy Policy)
&
(Terms & Conditions)
at SC Prime
Submit