Pothole Insurance

"*" indicates required fields

1Your Details

2Claim Details

3Alloy Wheels

4Bodywork

5Headlight

6Suspension

7Tyre

8Wheel

9Evidence

10Declaration

Please take reasonable care to provide true and accurate information and documentation. If you deliberately do not disclose a material fact, or if you withhold information, your claim may be refused and policy may be cancelled.

Customer Name*

First

Your First and Last Name as registered to the Policy or Warranty

Last

Policy Number*

The Unique Reference Number shown on your GAP Policy Schedule

Address*

Address Line 1

The address to which your Policy or Warranty is registered

Address*

Address Line 2

The address to which your Policy or Warranty is registered

Address*

City

The address to which your Policy or Warranty is registered

Address*

Postcode

The address to which your Policy or Warranty is registered

Phone Number*

Telephone Number and Area Code

Email Address*

A current e mail address by which we can contact you

Current Vehicle Registration Number*

Does your vehicle have a private plate?*

Yes, my vehicle has a private plate.

No, original plate.

Original Vehicle Registration Number*

Vehicle Make & Model*

Which claim types would you like to make?*

Alloy Wheels

Bodywork / Paint

Headlight

Suspension

Tyre

Wheel Alignment / Rebalancing

Do you have other insurance that may cover this incident?*

Yes

Please provide details of the other insurance*

Have you attempted to make a claim on the above insurance*

How many alloy wheels are damaged?*

Which alloy wheel was damaged?*

How is the alloy wheel damaged?*

Please provide a photograph of the damage*

Max. file size: 32 MB.

2 - Which alloy wheel was damaged?*

2 - How is the alloy wheel damaged?*

2 - Please provide a photograph of the damage*

Max. file size: 32 MB.

3 - Which alloy wheel was damaged?*

3 - How is the alloy wheel damaged?*

3 - Please provide a photograph of the damage*

Max. file size: 32 MB.

4 - Which alloy wheel was damaged?*

4 - How is the alloy wheel damaged?*

4 - Please provide a photograph of the damage*

Max. file size: 32 MB.

Description of Damages*

How many areas of bodywork damage are there?*

What area of the bodywork was damaged?*

What type of damage is it?*

Please provide a photograph of the damage*

Max. file size: 32 MB.

2 - What area of the bodywork was damaged?*

2 - What type of damage is it?*

2 - Please provide a photograph of the damage*

Max. file size: 32 MB.

3 - What area of the bodywork was damaged?*

3 - What type of damage is it?*

3 - Please provide a photograph of the damage*

Max. file size: 32 MB.

4 - What area of the bodywork was damaged?*

4 - What type of damage is it?*

4 - Please provide a photograph of the damage*

Max. file size: 32 MB.

Description of Damages*

Which headlight was damaged?*

Please provide a photograph of damage to the Front Nearside / Left / Passenger headlight*

Max. file size: 32 MB.

Please provide a photograph of damage to the Front Offside / Right / Driver headlight*

Max. file size: 32 MB.

Description of Damages*

Which suspension was damaged?*

Which area of the front suspension was damaged?*

Please provide a photograph of the damage to the front suspension*

Max. file size: 32 MB.

Which area of the rear suspension was damaged?*

Please provide a photograph of the damage to the rear suspension*

Max. file size: 32 MB.

Description of Damages*

How many tyres are damaged?*

Which tyre was damaged?*

How is the tyre damaged?*

Please provide a photograph of the tyre damage*

Max. file size: 32 MB.

2 - Which tyre was damaged?*

2 - How is the tyre damaged?*

2 - Please provide a photograph of the tyre damage*

Max. file size: 32 MB.

3 - Which tyre was damaged?*

3 - How is the tyre damaged?*

3 - Please provide a photograph of the tyre damage*

Max. file size: 32 MB.

4 - Which tyre was damaged?*

4 - How is the tyre damaged?*

4 - Please provide a photograph of the tyre damage*

Max. file size: 32 MB.

Description of Damages*

How many areas required wheel realignment / rebalancing?*

Which area is affected?*

What service is required?*

Please provide a photograph of the issue*

Max. file size: 32 MB.

2 - Which area is affected?*

2 - What service is required?*

2 - Please provide a photograph of the issue*

Max. file size: 32 MB.

3 - Which area is affected?*

3 - What service is required?*

3 - Please provide a photograph of the issue*

Max. file size: 32 MB.

4 - Which area is affected?*

4 - What service is required?*

4 - Please provide a photograph of the issue*

Max. file size: 32 MB.

Description of Issues*

Have you reported the incident to the local council?*

Yes

If no, please be aware that we may not be able to process your claim until your incident has been reported.

Local Council Reference Number*

Please provide evidence the incident has been reported to your Local Council*

Max. file size: 32 MB.

Please provide a photograph of the pothole*

Max. file size: 32 MB.

Please provide a copy of your repair invoice*

An itemised invoice inc. VAT

Max. file size: 32 MB.

Is there any other information you wish to make us aware of?

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.

Declaration*

I declare that all information I have provided is truthful and to the best of my knowledge, and that no material information has been intentionally withheld.

I declare that all property mentioned in this claim does belong to me and no other person has any financial interest in it.

Where necessary to investigate and progress my claim, I give my consent for you to seek information from other Insurers and/or organisations to check the answers I have provided and prevent fraud.

I understand that if I make a claim which is false, exaggerated or fraudulent in any way, my claim will not be paid and details of the fraud will be passed to the appropriate authorities for further investigation and potential prosecution.

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