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Home
About Us
Meet our Partners
Type of Accident
Accidents at Work
Road Traffic Accidents
Trips & Slips
Criminal Injury Claims
Clinical Negligence
Dental Negligence
Product Liability
Type of Injury
Back Injury Claims
Head Injury Claims
Facial & Dental Injury Claims
Fractures & Soft Tissue Injury
Post Traumatic Stress
Spinal Injury Claims
Whiplash Injury Claims
Compensation Calculator
Cycling Accidents (Cycle Aid)
Cosmetic Negligence
Types of Surgery
Contact Us
Cambridge
London
Manchester
Preston
Road Accident Claims Form
Road Accident Form
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1
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Full Name
(*)
Please let us know your full name
Address
(*)
Please provide details of your address
Telephone
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Mobile
Email
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National Insurance No
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Occupation/Job Title
(*)
Please enter your job title or 'n/a' if not applicable
Employer's name & address
Employer's name Employer's address
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Work Phone Number
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How did you hear of Cycle Aid/Simon A Holt & Co?
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Date of accident
(*)
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Time of accident
Please state time of accident
Location of accident
(*)
Please enter location of accident
Please describe the weather conditions
(*)
Please describe the weather conditions
Please describe the visibility
(*)
Please describe the visibility
Name and address of other driver involved
Name: Address: Male/Female:
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Name and address of other driver's insurers and policy number (if known)
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Registration number, make and model of vehicle involved in accident
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Who do you consider was at fault and why?
(*)
Please give your details of the accident
Could either party have avoided the accident?
(*)
Yes/No If yes, please state how:
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Was anything said by the other driver(s) afterwards?
(*)
Yes/No If yes, please state exactly what was said:
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Was any warning given?
If yes, how and by whom?
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Estimated speed at which you were travelling?
(*)
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Estimated speed at which the other vehicle was travelling
(*)
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Were there any witnesses to the accident?
Yes/No If yes, please give details: Name - Address - Telephone No -
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Was the matter reported to police?
Yes/No If yes, please state: Name and address of the Police Station - Telephone No - Date & time reported - Reference No - Name of reporting officer -
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Did the police attend the accident?
(*)
Yes
No
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Have the police advised you of any intended prosecution?
If yes, what offence is being considered by the police?
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Please describe your injuries & current symptoms?
(*)
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Were you taken to hospital?
If yes, which hospital? Name of Hospital - Address - Phone No -
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Were you detained in hospital?
If yes, for how long?
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Name of consultant attending you
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Hospital Reference No (Refer to appointment card)
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What treatment did you receive?
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Has any further treatment been recommended?
If so, what and by whom?
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Were x-rays taken?
If so, please state which hospital the x-rays were taken
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Have you seen your own GP?
If yes, please give dates: GP Name - Address - Telephone no of surgery -
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Have you returned to work?
If yes, how long were you absent?
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If no, will work continue to pay you?
Yes
No
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Are you receiving SSP or incapacity benefit?
If yes, please give details.
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Make, model and registration number of your vehicle
(*)
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Date of purchase
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Purchase price
(*)
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Is your vehicle on the road?
Yes/No If no, where is your vehicle stored and where might it be examined?
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Are storage charges being incurred?
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Extent of damage to vehicle
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Is your vehicle insured?
Yes/No If yes, with whom: Name - Address - Policy No - Estimated cost of repairs -
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Please give details of any damage to or loss of any personal property in the accident
(e.g. clothing, shoes, helmet, watch, jewellery etc). Please insert approximate values if you are unsure. Are receipts and invoices available?
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Travel Fares (give reasons for travel):
Please give any details on if you were out of pocket due to travel fares. (Bus, Taxi, Train)
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Medical expenses
Have you incurred any medical expenses? YES / NO. (All expenses must be fully justifiable) If YES; please give details:
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