Claim form

Your Accident.....Your Claim.....Your Choice

Did you know? In the event of an accident, you are entitled legally to use a solicitor, accident repair centre & taxi replacement service of your choice!!

DONT LET YOUR INSURANCE COMPANY PUSH YOU AROUND

Claims Form

First Name*

Surname*

Email*

Phone

Drivers Address*

1000 characters left

Occupation

DOB*

Injured Yes / No

Yes No

Owners details (If it is not the driver)

Owners Full Name

Owner Telephone

Owners Email

Owners Address

200 characters left

Own Insurance details

Insurance Company

Insurance Type

Policy No

Excess £

Vehicle details

Make & Model*

Reg No*

Location of Vehicle*

Can the Vehicle be made roadworthy?*

Vehicle condition

Accident Details

Accident date*

Time of accident*

Location of Accident*

Accident Description*

1000 characters left

Details of Passengers / Witness

Passenger / Witness

Passengers Information

1000 characters left

Details of other driver

Other drivers Name*

Other driver address

1000 characters left

Other driver tele number*

Other driver - Car make & Model

Other Driver Car Reg no*

Other driver insurance policy

Other driver insurance policy number

Acceptance for Data Processing*

Upload images

Fylde Coast Replacement Taxis

Accident Claim Form

Your Accident.....Your Claim.....Your Choice

Claims Form

In an accident

What we do

Address and contact