RTA Claim Form Please State Your Requirements Assessment of vehicle damage *YesNoReplacement motor vehicle *YesNoWould you like us to refer your vehicle to one of our approved repairers? *YesNoWere you or your passenger (s) Injured? *YesNoFull Name *Home Address *Contact Number *Email Address *Date of birth *NI Number *Occupation *Accident TypeSelect an optionRoad traffic accidentOption 2How many people were seated in your vehicle? *Select an option01234567891010 +Your Vehicle Current Location *Vehicle Make & Model *Vehicle Registration *Incident Date *Time of IncidentIncident Circumstances *Select an optionClaimant vehicle hit by party emerging from side roadClaimant vehicle hit in the rearClaimant vehicle hit whilst parkedAccident in a car parkAccident on a roundaboutAccident involving vehicle changing lanesOtherIncident circumstance detailsWeather Condition *Select an optionSunRainSnowIceFogFineOtherRoad Condition *Select an optionDryWetSnowIceMudOilFineOtherDamage On Your Vehicle *Select an optionRear damageFront damagePassenger side damageDriver side damageOtherIs your vehicle still driveable *YesNoWere the police involved? *YesNoPolice officer collar number?Input area/county of police station?Crime reference or log number?Police station telephone number?Your insurance details *Type Of Cover *Select an optionFully comprehensiveThird party, Fire & TheftThird party onlyTBC/To be confirmedWitness Details If Any *Select an optionYesNoTBC (to be confirmed)Witness full name?Witness address?Witness contact phone number?Taken time of work?Taken time of work?YesNoDo you wish to Claim for Loss of Earnings?Select an optionYesNoOtherOther driver (blameworthy) detailsAddress?Vehicle registration number?Vehicle make model and colour?Other driver's Insurer name and policy number?Images/Videos Taken At The Scene Of Accident *Select an optionNonePhotographic evidence attachedDash cam footageCCTV footage availableOtherIMPORTANT each section must be completed. If you are unable to provide the information we require, simply state ''unknown''By submitting this form, I agree to the (Privacy Policy) & (Terms & Conditions) at ICS HIRE LtdSubmit
