Insurance Claims

I have read and understand the guidance notes
YesNo
I have logged the fault online
YesNo

Please report this form on the ARA PIP system
Please enter your fault reference number

Section 2 - Incident Details
Date of incident (dd/mm/yyyy)
Time of incident

Hours

Minutes

Seconds

AM/PM
Specific Location
Street or Road Name / Number
This claim is in relation to
Vehicle DamageProperty DamagePersonal Injury
Please provide further information
Vehicle Registration (if applicable)
Please upload a sketch plan showing the exact location of the incident and, where applicable, pinpointing the defect in question
Please let us know the defect
Vehicle TyresVehicle WheelsOther Vehicle Defect
If you selected "Other Vehicle Defect" please detail below
Please upload copies of photograph/s of defect/s;
Please upload copies of property damaged and/or personal injuries , if applicable
Please upload copies of two (2) estimates/invoices for the repair to property damage.
Estimate one (1) / Invoice
Estimate two (2) / Invoice
Please state how the incident occurred
Independent Witnesses
Was the incident witnessed?
YesNo
If yes, please complete the following details
Name

First name

Last name
Address
City
County
Postcode
Name

First name

Last name
Address
City
County
Postcode

Section 4 - Damaged Item(s)
Please provide details of damaged item(s) (Please enclose 2 replacement estimates & original purchase receipt(s) where appropriate and provide photographs of damage where available) If damage is to a tyre, please specify if front or rear and confirm approximate mileage the damaged tyre had covered prior to the date of incident.
Description of Item
Date of Purchase
Purchase Price
Front Tyre
Left Front TyreRight Front Tyre
Rear Tyre
Left Rear TyreRight Rear Tyre
Approx mileage covered by tyre(s) prior to incident
Section 4a - Injuries Sustained
Please provide details of injuries sustained (if applicable)
Did you attend a doctor?
YesNo
If YES please state when
Date (dd/mm/yyyy) attended doctor
Time attended doctor

Hours

Minutes

Seconds

AM/PM
Did you attend a hospital?
YesNo
If YES please state when
Date (dd/mm/yyyy) attended hospital
Time attended hospital

Hours

Minutes

Seconds

AM/PM
Name of hospital
Hospital Address
County
County
Postcode

Section 5 - Declaration
Declaration
I declare that the information i have given on this form is correct and completeI understand that if I have given information that is incorrect, incomplete or false you may take action against me. This may include court actionI understand that the information held by you will be used for cross system and cross authority comparison purposes for the prevention and detection of fraud.I confirm that I have read understood and accept the terms and conditions contained within the guidance note.
General Data Protection Regulation (GDPR)
Under GDPR, we now have to supply data subjects with Privacy Notices that contain significantly more information than previously required under the Data Protection Act 1998. This is in order to meet new requirements about being transparent and providing accessible information to customers/individuals about how you are going to use their personal data so that they are fully informed and are aware of how they can exercise their rights under GDPR.
I hereby confirm that I give permission to the processing of my personal data
Yes
Name

First name

Last name
Electronic signature
Date (dd/mm/yyyy)

Public Liability Incident Report Form