MAKE A CLAIM "*" indicates required fields Step 1 of 14 - Policy Holder Details 7% Policy Holder DetailsPolicy Holder* Policy Number* Policy Holder Address*Email Address for Claims Contact* Phone Number* VAT Registered?* Yes No Driver SectionDriver Name* Date of Birth* DD dash MM dash YYYY Date passed test to drive the vehicle concerned* DD dash MM dash YYYY If the Driver has any of the following conviction codes currently on their license, please provide full details - AC, BA, CD40 to CD90, DD, DR,, IN, LC, MS, TT, UT or XXKnown Medical Conditions* Incident DetailsTime of Loss Hours : Minutes AM PM AM/PM Date of Loss* DD dash MM dash YYYY Accident Location* Please be as specific as possibleSpeed of all Vehicles involved*Weather/Road Conditions* Any Photographs taken?* Yes No Upload photographs taken Drop files here or Select files Max. file size: 128 MB. Our Insured VehicleVehicle Registration* Make/Model* Mileage* CCTV/Dashcam footage available?* Yes No Will you be claiming for damage to this vehicle?* Yes No Vehicle damage description*Vehicle driveable?* Yes No Please indicate damage area to policyholder vehicle Full Front End Drivers Side Front Drivers Side Rear Passenger Side Front Passenger Side Rear Rear Tailgage/Bumper Alloy Wheel Interior Engine Exhaust Other Please provide the other areas where the vehicle is damaged. Passengers/Injuries - Policy Holder VehicleHow many passengers were in your vehicle?* Names and Contact Details of any Passengers*Was anybody in this vehicle injured, if so, what injuries have been sustained?*Did an Ambulance attend the scene?* Yes No Attended Hospital?* Yes No Name of that Hospital Sketch and StatementPlease Provide a Statement of the accident below and draw sketch on your paper and upload that sketch below as well*Upload Sketch which you drawn on your paper Drop files here or Select files Max. file size: 128 MB. Do you consider yourself to be at fault for the incident?* Partially Yes No Third Party DetailsDriver Name Address. If incident involved a third party's property, please give full address detailsPhone Number Email Address Third Party Vehicle DetailsVehicle Registration Make/Model ColorSelect ColorWhiteRedYellowGreenPurpleOrangeInsurance Details Vehicle Damage DescriptionAny pre-existing damage? Yes No Vehicle Driveable? Yes No Please indicate damage area to vehicle Full Front End Drivers Side Front Drivers Side Rear Passenger Side Front Passenger Side Rear Rear Tailgage/Bumper Alloy Wheel Interior Engine Exhaust Other Please provide the other areas where the vehicle is damaged. Third Party passengers/InjuriesHow many passengers were in the third party vehicle at the time of collision? Were any of the passengers minors? (Under 16 years old)Did anybody in this vehicle complain of, suffer or incur visible injuries at the scene?If so, please provide full name and contact details if knownDid an ambulance attend the scene? Yes No Witnesses (If applicable)Witness Name Phone Number Email Address AddressIndependant? Yes No Police Details (If applicable)Did Police attend? Yes No Office Name/Badge Number Reference Number Station Did driver make a written statement? Yes No Any other comments/concerns you may wish to make known? DeclarationDeclaration I/We hereby declare that the above information and statements are true to the best of my/our knowledge and belief. I/We understand that you may ask for information from other Insurers to check the answers I/We have provided. No other insurance is in force and I/We will assist Nova Cover Services LTD with their esquires. Signature:*Date* DD dash MM dash YYYY Claim NumberClaim no Your Claim Number is going to be sent to you via upcoming email in PDF format. Please note it down for future correspondence. You will be assigned a Claims Handler, who will shortly be in touch with you. Also, click on Submit form button to proceed further. Thank You
