Incident

Incident details Independent witnesses

Date: Location: Name: Tel No.:

information
Time: Did the Police attend?: Y/N Address:
Name/station of officer:
Reference:
Name: Tel No.:
This guide is designed to help you make a claim if
you are involved in an incident. You do not need Address:
to send it to us, simply use it to record as much as Passengers in your vehicle
possible before making your claim. Passenger name: Injured? Treated? Nature of Injury

1 Stop...
1. Name: Tel No.:
2. Address:
3.

when it is safe to do so, whether 4.

or not the accident was your fault.

2 Check
Other vehicle involved: 1 Other vehicle involved: 2
Make: Model: Make: Model:
Reg No: Was the vehicle driveable? Y/N Reg No: Was the vehicle driveable? Y/N
if anyone has been hurt and call the Area of damage: Area of damage:

3
emergency services on 999 if necessary.
Driver name: Driver name:

Note...
Driver address: Driver address:

Driver telephone: Driver telephone:

4 Tell us...
as much information as you can, Insurer: Insurer:
use this form below as a guide.
Policy Number: Policy Number:
No of passengers in vehicle: No of passengers in vehicle:
Passenger name: Injured? Treated? Nature of Injury Passenger name: Injured? Treated? Nature of Injury
1. 1.

Call our Claims Team on 0333 043 2011 2. 2.

or register your claim online. We are 3. 3.

here to help 24 hours a day.
4. 4.

Photos Driver: Driver:

If possible, take photos of the incident showing
5. 5.
positions and registration numbers of the vehicles
involved, road layout and marks in the road, and
any vehicle damage. If more than 2 other vehicles are involved in the incident then please note down details on the back of this sheet.

Call today: 0333 043 2011

Claim online: my.1stcentralinsurance.com/customer/claims
Let us know about any incident as soon as possible (within 48 hours) whether you are intending to claim or not. Delays could affect the
way that the claim is dealt with and could also result in additional costs being incurred. 20230401/CF/1.0/v1.2