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Motassist Claim Form
Claimant's Details
All sections with a * must be completed
Motassist Policy No
(if applicable):
Where you referred
to us by:
Broker   Car Body Shop
If Yes, What is the name of the referrer?
Name on
Insurance policy *
Drivers Name *
Title *
Address *
Your Email *
Telephone  Day *
Telephone  Evening *
Driving Licence No *
Date of Birth *
List endorsements in last 5 years *
Vehicles Details
All sections with a * must be completed
Make *
Model *
Reg No *
Engine *
Pre-accident value
Would your vehicle FAIL the Mot test due to the damage caused by this accident?
Yes No Unsure
 
Cost of repairs [£]
Labour Parts
Your Insurance Details
All sections with a * must be completed
Policy Number *
Policy Excess *
Please Select
Fully
Comp 		Third Party
Fire & Theft 		Third Party
Only
Insurance Company *
Insurance Agent *
Agent Ref No
Witness Details
Please complete as many detals as possible
Witness Type
Passenger in
your vehicle		 Independent
witness
Name
Address
Witness Type
Passenger in
your vehicle		 Independent
witness
Name
Address
Injuries Sustained
Name
Injury
 
Name
Injury
Third Party Details
Please complete as many details as possible
Person at fault
Address
Telephone
Vehicle Make/Model
Vehicle Registration
Insurance Company
Address
Policy Number
Insurance Agent
Accident Details
All sections with a * must be completed
Place *
Date *
Brief Description
of Accident *
If this claim is a Non Fault incident do you want to claim directly from the Third Parties Insurance?
Yes No Unsure
Please Note: Claiming via your own insurance or through the third parties insurance policy will eventually result in the third party paying for all costs in settlement. Providing there are no liability issues. The benefit of you claiming via your own insurance is that your claim will be settled promptly, whereas claiming via the third party can result in serious settlement delays, as there are a number of additional factors to be considered.
Additional Comments
 
 
Authorised and regulated by the Financial Services Authority No. 309112
Regulated by the Ministry of Justice in respect of regulated claims management activities.
Our Ministry of Justice Authorisation Number is CRM4049. Company Reg No 3857691 Registered in England.