Personal Injury Form for Driver

    Step 1 of 5


    Full Name*


    Date of Birth*

    Nation Insurance Number*




    Step 2 of 5

    Defendant (Business or Private )

    If Business then Company name and Driver name, if private then Driver full name*


    Vehicle Registration*





    Insurance No*

    Policy Number*


    Explain in few word

    Is Your claim for vehicle damage proceeding through your own insurer?

    Vehicle Damages Claim

    Vehicle Inspection

    Storage company Name

    Storage company Address*

    Daily Rates (pounds only):

    Alternative vehicle

    Have you been provided a vehicle by your insurer?

    Do you require the use of an alternative vehicle?

    Have you been provided with the use of an alternative vehicle?

    Is the hire need still on going?

    Provider Detail Details

    Reference Number

    Start Date

    End Date

    Vehicle registration number

    Do you require the defendant’s insurer to provide you an alternative vehicle?

    Step 3 of 5


    Soft Tissue* YesNo

    Whiplash* YesNo

    Bone Injury* YesNo

    Other* YesNo

    Injury description*

    Work time Off*

    Still off work*

    How Many days*

    GP Attendance*

    When (when dates appear)


    Hospital Attendance*

    When (when dates appear)

    Did stay over night?


    Step 4 of 5

    Accident Detail

    How Many occupants?*

    Person 1*

    Person 1*

    Person 2*

    Person 1*

    Person 2*

    Person 3*

    Person 1*

    Person 2*

    Person 3*

    Person 4*

    Person 1*

    Person 2*

    Person 3*

    Person 4*

    Person 5*

    Person 1*

    Person 2*

    Person 3*

    Person 4*

    Person 5*

    Person 6*

    Can we contact them?*

    If no Why?*

    Do they want to claim also?*

    If no Why?*

    Can we contact them?*

    If no Why?*

    wearing a seat belt?

    If no Why?*

    Are you vehicle's owner?

    Vehicle Owner - Full Name*

    Vehicle Owner - Address*

    Vehicle Registration*




    Policy Number*

    Permission to drive?*

    If No why?*

    Accident Date*

    Accident Time*


    Weather Condition *

    Please add details

    Road Condition*

    Please add details*

    Accident circumstances description*

    Please add details*

    Accident Facts*


    Reference Number*

    Step 5 of 5

    Accident Involving

    Accidents involving a bus or a coach*

    Driver Name*

    Driver ID*

    Driver Description*

    Description of vehicle, including route number and direction of travel, colour and markings of vehicle*

    Approximate number of passengers on the bus/coach *


    Any Witness *

    Witness - Full Name*

    Witness - Address*

    Witness - Phone*

    Witness - Email*

    Can We Contact*

    Please Mention Why*


    Why does the claimant believe that the defendant was responsible for the incident?



    I am the claimant. I believe that the facts stated in this claim form are true. I understand that proceedings for contempt of court may be brought against anyone who makes, or causes to be made, a false statement in a document verified by a statement of truth without an honest belief in its truth.

    I have retained a signed copy of this form including the statement of truth

    If No Why

    Contact us

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        5 star review  Most reliable, reasonable and efficient solicitors in the area.. I have been using some big names solicitors in the area in past and they use to charge hefty amounts of fees and after that they never use to have time to listen to us with our queries.. Mr. Imran at Privilege Solicitors replied me straight away with any query I had.. I didn't had to go through with stress.. they know what are they doing and they are best in it.. thank you team Privilege for looking after your clients and doing so hard work

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