ULR policy form

REFERENCE

Reference number(Required)

YOUR PERSONAL DETAILS

Title(Required)

First name(Required)

Surname(Required)

Date of Birth(Required)

Name of registered keeper of vehicle(Required)

Please confirm who was driving your vehicle when the incident occurred(Required)

Street address(Required)

Town(Required)

County(Required)

Postcode(Required)

Tel (work)

Tel (home)(Required)

Tel (mobile)(Required)

E-Mail(Required)

UNINSURED LOSSES

Please note that it is important to provide all receipts / documentation by post, where available.

Have you sustained:

1. Policy Excess

Yes

No

If yes, please state the amount

2. Personal Injury

Yes

No

A. If you have answered Yes to the above, please contact your legal expense insurance providers (if you have the benefit of this insurance), and provide us with the Solicitor's details that will be dealing with your Personal Injury claim.

B. If you have answered yes to the above, but do not have legal expense insurance and have Solicitors acting on your behalf in relation to your Personal Injury claim, please provide their details, including the claim reference.

3. Hire Charges – Have you been provided with a replacement vehicle?

Yes

No

If yes, please advise the Company's name (for example: Accident Exchange, or Enterprise) and provide their reference number.

Please note: you may be liable for the Hire Car charges should you fail to notify us.

4. If you answered yes to the above, please confirm for what purpose you required the hire vehicle? E.g. For travelling to work.

5. Please confirm if you had the financial means to pay for a hire vehicle of your own accord, without the need of hiring a credit hire vehicle?

Yes, I could afford to hire another vehicle

No, I could not afford to hire another vehicle

If your answer is no and legal proceedings are issued, the court will request proof that you did not have the financial means to pay for your own hire vehicle at the time of the incident.

6. Loss of earnings

Yes

No

If yes, please state the amount

Please provide a clear breakdown of how your loss is calculated and supply any supporting documentation to us via email or post quoting your name and reference number.

7. Storage and recovery charges

Yes

No

Please give details

Please provide a clear breakdown of how your loss is calculated and supply any supporting documentation to us via email or post quoting your name and reference number.

8. Loss of use

Yes

No

If yes, please give details of the period of time that you were unable to use your vehicle and why e.g. undrivable, repairs etc.

Please note: You can only claim loss of use if you were without a vehicle.

9. Any other losses

Yes

No

Please give details

Please provide a clear breakdown of how your loss is calculated and supply any supporting documentation to us via email or post quoting your name and reference number.

DESCRIPTION OF ACCIDENT

Please provide a brief statement as to the circumstances of the accident, including any details you may have obtained for the third party

Please confirm the exact accident location

Please provide the names and addresses of any passengers or witnesses, if any

If the matter proceeds, can you confirm that you will/the driver will attend court to give evidence?(Required)

Yes

No

YOUR SOLICITORS

If solicitors are acting on your behalf please give their details including reference:

Reference number

First name

Surname

Street address

Town

County

Postcode

Tel (work)

Tel (home)

E-Mail

Today's date(Required)

Please note that depending on the answers given above, you may be required to sign a statement at a later date.

Please proceed to press the submit button below and the completed form will be sent to us.

As you have completed the form electronically you do not need to send a paper copy or call to confirm the details.

ULR Policy Form

REFERENCE

YOUR PERSONAL DETAILS

UNINSURED LOSSES

DESCRIPTION OF ACCIDENT

YOUR SOLICITORS

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