Domino's Motor Claim Report

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Address of Policy Holder *

Store Number (if applicable)

Name of Driver *

Address of Driver *

Drivers Phone Number *

Drivers Date Of Birth *

Type of Licence Held

Full Private Car Full + Motorbike Full + HGV Class 1 Full + HGV Class 2 Full + HGV Class 3 Provisional + CBT

How long licence held *

Date driving licence test passed for class of vehicle driven *

Use of Vehicle at time of accident *

Any driving convictions *

Yes No

If yes then details of convictions (Date, Offence Code, Number of points, Fine, Ban)

Is the driver going to be prosecuted for any offence relating to drink or drugs *

Yes No

Is the driver aware of any pending prosecutions *

Yes No

Any Disabilites *

Yes No

If yes the details of disabilities and if DDAI notified (if required)

Telematics: Driver's Reference Number

Is the Insured vehicle owned by the Policyholder or the driver? *

Make and model of the Insured vehicle *

Registration number of the Insured vehicle *

Damage to insured vehicle *

Are you at fault for the accident *

Yes No

Date of accident *

Time of accident *

Location of incident *

Description of accident *

Police Involvement /details *

Speed of vehicle *

Third Party Name *

Third Party Address *

Third Party Telephone *

Was the third party injured? *

Yes No

Make, model and registration number of other vehicle *

Nature of damage to other vehicle *

Approximate speed of other vehicle *

Name, address and phone number for any other vehicle/property involved *

Details of passengers in the other vehicle including gender and seating position or state none *

Please give full details of any additional vehicles involved in the accident *

Please give details of any witnesses

Policy Holder Email *

Policy Holder email address (Karshan Group)

If you have an image diagram or documentation to support your claim please upload it below (filetypes: PDF|DOC|DOCX|BMP|GIF|JPEG|JPG|PNG|XLS|XLSX - max 6MB).

DOMINO’S MOTOR CLAIM REPORT

Motor Claim Report

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