Your DetailsWe would advise to not accept the motor insurer offer until we have checked that it is fair. Please contact your motor insurance and give your permission for us to speak to them on your behalf Before completing the form, please assemble and read your policy documentation fully to assist you. You will be required to submit copies of: Sales Invoice (not vehicle order form) The documentation provided when you purchased your vehicle by the selling dealer. This will confirm the purchase price of the vehicle, mileage, specification, age, etc. GAP Insurance Policy Schedule Motor Insurers Policy Schedule (showing comprehensive coverage) This document will be provided by your motor insurer at the point of sale, and can be obtained directly from them if you do not have a copy. The document confirms information such as who is insured to drive the vehicle, the cover level (Comprehensive, third party, fire, & theft, or third party only), term of cover, vehicle insurer. Motor Insurers Policy Wording V5 Any letters/emails from motor insurers confirming settlement figure. If applicable: Finance agreement The document provided when you agreed the finance for the vehicle. This document will contain information such as length of agreement, amount borrowed, repayment schedule. Finance early settlement figure This document will need to be obtained from your finance company. If you contact them and ask to settle the agreement early, they will provide this document to you. Third party details Police correspondence (Note: Please do not send original documents or Photographs. Scanned PDF Copies Only)GAP Policy NumberThe Unique Reference Number shown on your GAP Policy ScheduleCustomer Name*Your First and Last Name as registered to the Policy or Warranty First Last Address*The address to which your Policy or Warranty is registered Street Address Address Line 2 City Region Postcode Telephone Number*Telephone Number and Area CodeMobile NumberTelephone Number and Area CodeEmail AddressA current e mail address by which we can contact you Occupation*Your current professional roleDo you have any other GAP Insurance on this vehicle?*YesNoYour ClaimVehicle Registration Number*If your vehicle has a private plate, please enter that and the original vehicle registration as we require both to process your claim.Private Plate? Yes, my vehicle has a private plate. Original Vehicle Registration NumberThe VRM at time of total private or originalMake*The vehicle Make e.g. VolkswagenModel/ Trim*The vehicle Model e.g. Golf GTIDate of PurchaseThe date you first purchased the product Date Format: DD slash MM slash YYYY TransmissionIs the vehicle Manual or AutomaticDate of First RegistrationAs shown on your vehicles Log Book (V5 Certificate) Date Format: DD slash MM slash YYYY Purchase Price*The price you paid for the vehicle as per the sales invoice (not required on lease vehicles)Vehicle SupplierName of Registered Keeper*As shown on your vehicles Log Book (V5 Certificate) First Last Current Mileage*The mileage at time of total lossDate of Loss*The date the incident that led to the total loss occurred Date Format: DD slash MM slash YYYY Time of LossThe time the incident that led to the total loss occurred. If total loss occurred due to a theft and the time is unknown please put a time frame e.g. between 07.30PM 21/10/2019 and 09.00am on 22/10/2019) : HH MM AM PM Fault/ Non-FaultAre you at fault or non-fault for claim. This can be confirmed by whether you have to pay the excess or notLocation of Incident*The place the incident occurred e.g. A47 by SwaffhamDetails of Incident*Details of the incident that led to the loss and who was driving, or details of theft.Name last person to drive the vehicleLeave blank if no one was driving the vehicle at the time of the incident.Motor Insurance DetailsWho is Your Motor Insurer*The firm you insure the car with e.g. Direct LineDate Insurer NotifiedThe date that you notified your motor insurer. Please note if you are claiming through the 3rd party insurer or through an accident management company your motor insurer still needs to be notified Date Format: DD slash MM slash YYYY Policy NumberThe Unique Reference Number shown on your Motor Insurance Policy ScheduleClaim NumberThe claim number of your motor insurer claim or accident management company claimPolicy Start Date*Your motor insurance policy start date Date Format: DD slash MM slash YYYY Policy End Date*Your motor insurance policy end date Date Format: DD slash MM slash YYYY Have you received an offer from your Insurer*How much your motor insurer, 3rd party insurer or accident management company has offered for the total loss of your vehicle prior to any deductions such as excess or outstanding premiumWe would advise to not accept the motor insurer offer until we have checked that it is fair. Please contact your motor insurance and give your permission for us to speak to them on your behalfHave you accepted this offer?*YesNoTotal Policy ExcessTotal excess on your motor insurance policy regardless of whether you have to pay this or notDo you have to pay an excess for this incident?YesNoHave you had any motor insurance claims in the last 3 years including third party claims?*YesNoFinanceFinance*YesNoName of finance company*The firm you financed the car through e.g. Blackhorse FinanceAgreement number*The number of your finance agreement usually located on the finance agreement or welcome letter from your finance companyDate finance company notified of loss*The date you notified your finance company that the vehicle is a total loss (if you not done this, you will need to notify them) Date Format: DD slash MM slash YYYY Whose name is the finance in*The name of the person who took the finance outThird Party DetailsNameThe name of the other driver involved in the accident, N/A if total loss was a theftVehicle registration numberThe vehicle registration of the other driver involved in the accidentComprehensive insurance policy numberThe motor insurance policy number of the other driver involved in the accidentPolice DetailsHave the police been notified*YesNoName of police station*The name of the constabulary who attended, if this was reported via 111 please state 111Incident report number*The unique reference number for the incident or theft that was provided by the policeName/No of reporting officerThe name of the police officer who attended the incident or who logged the theftWere you breathalysed*YesNoWhat was the resultDate of report* Date Format: DD slash MM slash YYYY Additional InformationWe advise not to accept any offer form the motor insurer until a current market valuation has been completed by ourselves. Please contact your motor insurance and give your permission for us to speak to them on your behalf Attach Documents Drop files here or Accepted file types: jpg, png, pdf. Our file upload accepts .jpg, png, pdf. Individual file size is limited to 16mb.DeclarationIs there any other information you wish to make us aware of?Please check all your answers carefully before submitting your claim.Declaration* I hereby certify that I am the policy holder and all the information given in this form is truthful, accurate and complete. Please be aware that a fraudulent or exaggerated claim may result in a complete loss of any entitlement under the policy. Please note; Our privacy policy can be found here.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
