Your DetailsBefore completing the form, please ensure you have read your documentation fully. We recommend you have the documentation to hand to help you complete the form. To complete the form you will require: Policy / Warranty Documentation Details of the repair costs or estimate Your vehicle details including current mileage Date Fault Noticed*The date you very first noticed the fault Date Format: DD slash MM slash YYYY Date of Incident* Date Format: DD slash MM slash YYYY Policy NumberThe Unique Reference Number shown on your 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 Your RepairRepairer NameThe name of the Firm carrying out the repairs to your vehicleTelephone NumberTelephone Number and Area CodeEmail AddressA current e mail address by which we can contact the repairer Vehicle 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 first registrationMakeThe vehicle Make e.g. VolkswagenModelThe vehicle Model e.g. GolfCurrent Mileage*The mileage at time of repairCause of FailurePuncturedSplitPotholedTread Depth (Across Damaged Tyre)Please measure tread depth using an appropriate tool eg ruler or digital / analogue tyre gaugeTyre Size*Tyre TypeRun FlatStandardWhat tyre is damaged*Front Passenger SideBack Passenger SideFront Driver SideBack Driver SideCost Per Item*The total cost including VATNumber Required*The number of tyres requiredTotal CostPhotos*Our file upload accepts jpg, gif, png files. Individual file size is limited to 16mb. Please upload two photos, one showing damage, and one across tyre showing tread depths. Drop files here or Accepted file types: jpg, gif, png. DeclarationPlease check all your answers carefully before submitting your claim.Is there any other information you wish to make us aware of?Declaration* I hereby certify that I am the policy holder and all the information given in this form is truthful, accurate and complete. Dated Date Format: DD slash MM slash YYYY 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.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
