Claim Online

Please follow these instructions:

Fill out the form below,click the Submit Details button.Your details will then be emailed to our claims department.

Alternatively print the form, complete it and either post it to the address shown or Fax it on 01274 201656.

A Personal injury Specialist will phone you with in 45 min of recieving the form.
Please note that all information submitted is treated as strictly confidential.

Enter Your Personal Details
						Contact Address
Drivers Name
Occupation
Tel Number(Day)
Tel Number(Eve)
Email Address
Enter Details About The Accident						Enter Location of Accident
Date of Accident
Time of Accident
If Police Attended Enter Details Below						Enter Brief Details of the Accident
Name of Officer
Police Station
Enter Vehicle Details of Fault Vehicle
Make
Model						Address of Insurance Company
CC
Registration
Insurance Company
Type of Insurance		Third party Third party Fire&Theft Full Comprehensive
Policy Number
Submit your Details
If you are sure all your details are correct then simply click the submit button to send these details right away. If you prefer simply print this form and either fax or post it to us at the address shown to the right.						Floors 1- 4 PIA House 121 Legrams Lane Bradford West Yorkshire England, BD7 2AA
Please tick the boxes below if you would like us to contact you.						phone 01274 201655 Fax     01274 201656
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