Road traffic accident claim

New Claim Form

Please complete the form as fully as possible. Fields marked * are required.

Fairway staff

Prepare a link to send

Enter the recipient’s details, then open an email on your phone or in Outlook on your computer, send a WhatsApp message, or copy the link.

Who is completing the form? *Recipient name *Recipient email *Fairway reference

Agent and broker details

Agent nameAgent referenceBroker nameBroker referenceForm date *

Client details

Title *First name(s) *Surname *Address line 1 *Address line 2Address line 3City *CountyPostcode *Mobile contact number *Home contact numberWork contact numberEmail address *Date of birth *National Insurance numberOccupation

Client driver details (if different)

Leave this section blank if the client was the driver.

TitleFirst name(s)SurnameAddress line 1Address line 2Address line 3CityCountyPostcodeMobile contact numberHome contact numberWork contact numberEmail addressDate of birthNational Insurance numberOccupation

Client vehicle details

Vehicle make *Vehicle model *Vehicle colourVehicle registration *Insurance typeInsurer nameInsurer telephone numberPolicy number

Damage to vehicle

Accident details

Accident date *Accident timeLocation of accident *

Description of accident *

Third-party details

TitleFirst nameSurnameAddress line 1Address line 2Address line 3CityCountyPostcodeTelephone number

Third-party vehicle and insurance details

Vehicle makeVehicle modelVehicle colourVehicle registrationInsurance typeInsurer nameInsurer telephone numberPolicy number

Damage to third-party vehicle

Witness 1

TitleFirst nameSurnameAddress line 1Address line 2Address line 3CityCountyPostcodeTelephone numberEmail address

Witness 2

TitleFirst nameSurnameAddress line 1Address line 2Address line 3CityCountyPostcodeTelephone numberEmail address

Driving licence details

Driving licence numberDate test passedDate of issueExpiry date

I confirm that the information provided in this form is true to the best of my knowledge and belief. *