Claims Form - Clegg Gifford

We are sorry to learn you have been involved in an accident.

This claim notification page will help you through your incident. Please complete our online question set and a claims handler will then return to you in the next 3 working days.

Please note this form only applies to motor claims including fire and theft, if you wish to report anything else then please contact us for assistance on 0333 313 3131.

Notification Details

Who is reporting this Claim? Policy HolderNamed DriverThird PartyBroker

Name/Broker

Policy Number

Reference

Telephone

Email

Policy Number

First Name

Last Name

Telephone

Mobile

Email

Address 1

Address 2

Town

Postcode

Incident Details

Please confirm the incident type: Road Traffic AccidentTheftFire

Date of Theft / Fire

Time / Last Seen

Location of Theft / Fire

Who was the last user of the vehicle? PolicyholderNamed DriverOther

Circumstances

Was the vehicle fitted with a tracker? YesNo

Has vehicle been located? NoYes

Location of vehicle

Insured Driver

Was the policy holder the driver?YesNo

Date of Birth

Years License Held

Do you hold a UK license?YesNo

Do you hold a UK license? YesNo

Name (if different from policy details)

Date of Birth

Address (If different from policy details)

Address2

Town

Postcode

Telephone Number

Email

Years License Held

Insured Vehicle

Registration

Make

Model

Date of purchase if known

Who is the Registered Keeper of this vehicle? Policy HolderOther - Please Specify

Registered Keeper

Other Keeper

As you are a "Third Party" making this claim you do not need to fill in this step please click the next button to continue to the next step.

Owner Damage

Are you intending to make a claim for your own vehicle damage via your comprehensive policy? YesNo

Please give a brief description of damage sustained to your vehicle:

Do you believe your vehicle to be Roadworthy? YesNo

Current Vehicle Location:

Third Party

Was there a third party involved?YesNo

Do you have Third Party Details? YesNo

Third Party Details

First Name

Last Name

Registration

Make

Model

Color

Insurer

Insurer-Reference

Damage

Roadworthy? YesNo

Address

Address 2

Town

Postcode

Telephone Number

Do you know of any injuries being sustained? YesNo

If yes please specify

How many occupants in the third party vehicle (Including the driver)? If there is one or more third party, then please click the button below and enter the information

Witnesses Accounts

Is your vehicle fitted with any Telematics / Dash Cam or was there any CCTV footage or witnesses available for the incident ? YesNo

What Evidence is available, please select Witness evidenceCCTVTelematicsDash Cam

Name

Telephone

Email

Address

Do you know of any CCTV in the area – if so please specify?

Police Information

Was the claim Reported to the police? YesNo

Date Reported

Police Reference

Police Station / Department

Address 1

Address 2

Town

Postcode

Attended the Scene? YesNo

Attending Officer

Was Anyone Charged?

Document Uploads

File Uploads are restricted to a maximum size of 1GB Do you have any uploads to support your claim? YesNo

Images? YesNo

CCTV Footage? YesNo

Dashcam? YesNo