Insurance Claim

Claimant Details

Title: *

First Name: *

Last Name: *

Date Of Birth (DD/MM/YYYY):

Telephone Number: *

Mobile Number:

Email Address:

If you do not provide an email address we will not be able to send you a confirmation

Occupation:

House Number or Name: *

Post Code: *

Address Line 1: *

Address Line 2:

Town/Village: *

County: *

Representation

Do you have Legal Representation or an Agent:

Yes

Title:

First Name: *

Last Name: *

Relation to claimant (Solicitor, Agent, etc): *

House Number or Name: *

Post Code: *

Address Line 1: *

Address Line 2:

Town/Village: *

County: *

Details of the Incident

When did the incident happen (DD/MM/YYYY): *

What time did the incident happen (HH:MM): *

Where did it happen (exact location e.g. house no/street name and town/village): *

How did it happen?: *

Please tell us why you believe the council is legally responsible for your loss: *

Did anyone else witness your incident:

Yes

Please provide their name and contact details:

Title:

First Name: *

Last Name: *

Telephone Number:

Mobile Number:

Email Address:

House Number or Name: *

Post Code: *

Address Line 1: *

Address Line 2:

Town/Village: *

County: *

Did you involve the police:

Yes

Police incident number:

Police Station: *

Post Code:

Address Line 1:

Address Line 2:

Town/Village:

County:

Other Information relating to the Incident

Did you notify the council of the incident:

Yes

If you have any receipts, photographs or quotes relating to the incident, then these can be provided later in the form

Who did you notify within the council:

Title:

Name: *

When did you inform the council(DD/MM/YYYY): *

Property Damage

If the incident involved a defect, did you notify the Council before your incident:

Yes

Who did you notify within the council:

Title:

Name: *

When did you notify to the council(DD/MM/YYYY): *

Please remember to attach any receipts and/or repair estimates with this form. Also please be sure to include the vehicle make, model and registration number if your vehicle was damaged.

Description of item/s Lost/Damage: *

Estimated Cost to Repair or Clean: *

Your Insurer's Details

Are you claiming damage to a vehicle or property:

Yes

Insurer's name: *

Claim number:

Policy number: *

Insurer's building name/number: *

Post Code: *

Address Line 1: *

Address Line 2:

Town/Village: *

County: *

Injury

Are you claiming for an injury:

Yes

If you suffered an injury as a result of the incident the council and it's claims and legal agents have a duty to advise the Department of Work and Pensions (Compensation Recovery Unit) you have submitted a claim for compensation. To ensure we only pass on the correct information, you must provide all the relevent information requested.

National Insurance Number: *

Description of Injuries resulting from the incident: *

Doctors Details:

Title:

First Name: *

Last Name: *

Doctors Address:

Hospital/Clinic: *

Town: *

County: *

Did you consult your doctor about these injuries or attend hospital after the incident:

Yes

Please tell us where you attended and the name of the Doctor / Clinician who treated you:

Title:

First Name: *

Last Name: *

House Number or Name: *

Post Code: *

Address Line 1: *

Address Line 2:

Town/Village: *

County: *

Are you still receiving treatment:

Yes

Please provide details:

Are you employed:

Yes

Employer Name: *

Employer Telephone Number: *

Employer Email Address:

Employee Number:

Contact Title:

Contact First Name: *

Contact Last Name: *

Post Code: *

Address Line 1: *

Address Line 2:

Town/Village: *

County: *

Dates of absence: *

Evidence

please attach a single image file containing all of your evidence. The only files allowed are jpg, gif or png. Maximum picture size 5Mb:

Declaration

Have you read the information pack?:

Yes

Terms :

I certify that I have read, understand and accept the information and terms provided by the Borough Council of King’s Lynn and West Norfolk – Tick Box to confirm

Yes

Declaration :

I certify that to the best of my knowledge and belief, the information supplied by me in this online claim form is true. I understand that any alleged loss that is found to have been fraudulent, falsely stated or exaggerated will be passed to the Police and may be subject to criminal prosecution. I understand that the personal information collected on this online claim form will be used by the Borough Council of King’s Lynn and West Norfolk to process this claim and be retained securely. I understand that this information will only be disclosed to other agencies in connection with processing this claim and identifying potential cases of fraud. This includes periodic data matching exercises such as the National Fraud Initiative. Those agencies will be similarly subject to the requirements of the Data Protection Act.

Have you read and understood the declaration?:

Yes