Form name:
<div class="rounderCornerMiddle"> <div id="wrapper"> <div class="headerText"> PRIVATE MOTOR VEHICLE CLAIM FORM</div> <fieldset> <legend>Your Details </legend> <div class="itemField"> <div class="listDiv2"> Full name: </div> <div class="listDiv"> <input type="text" name="txbFullName" /></div> </div> <div class="itemField"> <div class="listDiv2"> Your address: </div> <div class="listDiv"> <textarea name="txbAddress" rows="4" cols="22"></textarea></div> </div> <div class="itemField"> <span class="blueBolderText">Contact details: </span></div> <div class="itemField"> <div class="listDiv2"> Address</div> <div class="listDiv"> <textarea name="txbContactAddress" rows="4" cols="22"></textarea></div> </div> <div class="itemField"> <span class="blueBolderText">Telephone: </span></div> <div class="itemField"> <div class="listDiv2"> Work: </div> <div class="listDiv"> <input type="text" name="txbWork" /></div> </div> <div class="itemField"> <div class="listDiv2"> Home: </div> <div class="listDiv"> <input type="text" name="txbHome" /></div> </div> <div class="itemField"> <div class="listDiv2"> Mobile: </div> <div class="listDiv"> <input type="text" name="txbMobile" /></div> </div> <div class="itemField"> <div class="listDiv2"> Email: </div> <div class="listDiv"> <input type="text" name="txbEmail" /></div> </div> </fieldset> <fieldset> <legend>PERSON DRIVING OR IN CHARGE OF VEHICLE </legend> <div class="itemField"> <div class="listDiv2"> Full name: </div> <div class="listDiv"> <input type="text" name="txbInChargeName" /></div> </div> <div class="itemField"> <div class="listDiv2"> Your address: </div> <div class="listDiv"> <textarea name="txbInChargeAddress" rows="4" cols="22"></textarea></div> </div> <div class="itemField"> <span class="blueBolderText">Telephone: </span></div> <div class="itemField"> <div class="listDiv2"> Work: </div> <div class="listDiv"> <input type="text" name="txbInChargeWork" /></div> </div> <div class="itemField"> <div class="listDiv2"> Home: </div> <div class="listDiv"> <input type="text" name="txbInChargeHome" /></div> </div> <div class="itemField"> <div class="listDiv2"> Mobile: </div> <div class="listDiv"> <input type="text" name="txbInChargeMobile" /></div> </div> <div class="itemField"> <div class="listDiv2"> Email: </div> <div class="listDiv"> <input type="text" name="txbInChargeEmail" /></div> </div> <div class="itemField"> <div class="listDiv2"> Date of birth</div> <div class="listDiv"> <input type="text" name="txbDateOfBirth" /></div> </div> <div class="itemField"> <div class="listDiv2">Occupation</div> <div class="listDiv"> <input type="text" name="txbOccupation" /> </div> </div> <div class="itemField"> <div class="listDiv2"> Relationship to policyholder</div> <div class="listDiv"> <input type="text" name="txbRelationship" /></div> </div> <div class="checkboxItemField"> <label>Is he or she the main driver of the vehicle?</label> <input type="radio" name="rbtnMainDriver" value="Yes" /> <input type="radio" name="rbtnMainDriver" value="No" /> </div> <div class="itemField"> <div class="listDiv2"> Please give driver's license type and number and its validity</div> <div class="listDiv"> <input type="text" name="txbDriversLicence" /></div> </div> <div class="checkboxItemField"> <label>Has the driver had any previous accidents in the last five years?</label> <input type="radio" name="rbtnPreviusAccidents" value="Yes" /> <input type="radio" name="rbtnPreviusAccidents" value="No" /> </div> <div class="itemField"> <div class="listDiv2"> If yes, please provide details.</div> <div class="listDiv"> <textarea name="txbPreviousAccidents" rows="4" cols="22"></textarea></div> </div> <div class="checkboxItemField"> <label>Has the driver ever been charged or convicted of any criminal convictions (including traffic offences, but not parking offences), or is the driver currently facing a prosecution?</label> <input type="radio" name="rbtnCharged" value="Yes" /> <input type="radio" name="rbtnCharged" value="No" /> </div> <div class="itemField"> <div class="listDiv2"> If yes, please list each offence or prosecution and each sentence received. </div> <div class="listDiv"> <textarea name="txbCharged" rows="4" cols="22"></textarea></div> </div> <div class="checkboxItemField"> <label>Has the driver had any medical condition that could affect his or her fitness as a driver (including but not limited to diabetes, epilepsy, heart conditions, physical or mental illness or disability)?</label> <input type="radio" name="rbtnMedicaCondition" value="Yes" /> <input type="radio" name="rbtnMedicaCondition" value="No" /> </div> <div class="itemField"> <div class="listDiv2"> If yes, please list full details. </div> <div class="listDiv"> <textarea name="txbMedicalCondition" rows="4" cols="22"></textarea></div> </div> <div class="checkboxItemField"> <label>Had the driver consumed alcohol, drugs or any intoxicating substance within 12 hours immediately before the accident?</label> <input type="radio" name="rbtnConsumed" value="Yes" /> <input type="radio" name="rbtnConsumed" value="No" /> </div> <div class="itemField"> <div class="listDiv2"> If yes, please list type, purpose and quantity. </div> <div class="listDiv"> <textarea name="txbConsumed" rows="4" cols="22"></textarea></div> </div> <div class="checkboxItemField"> <label>Has the driver undergone a breath or blood test since the accident?</label> <input type="radio" name="rbtnUndergone" value="Yes" /> <input type="radio" name="rbtnUndergone" value="No" /> </div> <div class="itemField"> <div class="listDiv2"> If yes, please indicate result. </div> <div class="listDiv"> <textarea name="txbUndergone" rows="4" cols="22"></textarea></div> </div> </fieldset> <fieldset> <legend>VEHICLE DETAILS </legend> <div class="itemField"> <div class="listDiv2"> Vehicle registration number</div> <div class="listDiv"> <input type="text" name="txbVehicleRegistration" /></div> </div> <div class="itemField"> <div class="listDiv2"> Warrant of fitness number</div> <div class="listDiv"> <input type="text" name="txbWarrent" /></div> </div> <div class="itemField"> <div class="listDiv2"> Year of manufacture</div> <div class="listDiv"> <input type="text" name="txbManfacture" /></div> </div> <div class="itemField"> <div class="listDiv2"> Make/model</div> <div class="listDiv"> <input type="text" name="txbMakeModel" /></div> </div> <div class="itemField"> <div class="listDiv2"> Date of purchase and purchase price</div> <div class="listDiv"> <input type="text" name="txbPurchageDate" /></div> </div> <div class="itemField"> <div class="listDiv2"> CC rating</div> <div class="listDiv"> <input type="text" name="txbCCRating" /></div> </div> <div class="itemField"> <div class="listDiv2"> Name and address of registered owner</div> <div class="listDiv"> <input type="text" name="txbRegisteredOwner" /></div> </div> <div class="checkboxItemField"> <label>Is the vehicle the subject of any hire, lease or finance arrangement?</label> <input type="radio" name="rbtnFinanceArrangement" value="Yes" /> <input type="radio" name="rbtnFinanceArrangement" value="No" /> </div> <div class="checkboxItemField"> <label>Has the vehicle been modified in any way?</label> <input type="radio" name="rbtnModified" value="Yes" /> <input type="radio" name="rbtnModified" value="No" /> </div> <div class="checkboxItemField"> <label>Is there any other insurance on the vehicle or accessories?</label> <input type="radio" name="rbtnAccessories" value="Yes" /> <input type="radio" name="rbtnAccessories" value="No" /> </div> <div class="itemField"> <div class="listDiv2"> If you have answered yes to any of the above questions, please write full details below. </div> <div class="listDiv"> <textarea name="txbAnswered" rows="4" cols="45"></textarea></div> </div> <div class="checkboxItemField"> <label>Was the vehicle being used with the policyholder's knowledge and permission?</label> <input type="radio" name="rbtnPermission" value="Yes" /> <input type="radio" name="rbtnPermission" value="No" /> </div> <div class="itemField"> <div class="listDiv2"> If commercial vehicle, state nature and weight of goods carried</div> <div class="listDiv"> <input type="text" name="txbStateNature" /></div> </div> </fieldset> <fieldset> <legend>ACCIDENT DETAILS </legend> <div class="itemField"> <div class="listDiv2"> Please describe the circumstances of the accident. </div> <div class="listDiv"> <textarea name="txbAccidentCircumstances" rows="4" cols="35"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> What were the date, time and lighting conditions? </div> <div class="listDiv"> <textarea name="txbDateTimeConditions" rows="4" cols="45"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> Where did the accident happen? </div> <div class="listDiv"> <textarea name="txbWhereHappen" rows="4" cols="35"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> What were the weather conditions? </div> <div class="listDiv"> <textarea name="txbWeatherConditions" rows="4" cols="45"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> What were the road surface conditions? </div> <div class="listDiv"> <textarea name="txbRoadSurfaceConditions" rows="4" cols="45"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> What was the speed limit in the area of the accident, and what was your speed immediately before the accident? </div> <div class="listDiv"> <textarea name="txbSpeedLimit" rows="4" cols="45"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> Please upload the picture of the accident (including lay-out of road, approximate measurements, names of streets and roads, position of vehicles and persons involved, direction of vehicles which were travelling, registration marks of all vehicle, any road markings, road signs, traffic lights, street lights, pedestrian crossings).</div> <div class="listDiv"> <input type="file" name="txbSketchOfAccident"/></div> </div> <div class="checkboxItemField"> <label>Did the Police attend the accident?</label> <input type="radio" name="rbtnPoliceAttend" value="Yes" /> <input type="radio" name="rbtnPoliceAttend" value="No" /> </div> <div class="itemField"> <div class="listDiv2"> </div> <div class="listDiv"> <textarea name="txbPoliceAttend" rows="4" cols="45"></textarea> </div> <div class="itemField"> <div class="listDiv2"> If yes, please advise date reported/station/police file number. </div> <div class="listDiv"> <textarea name="txbDateReported" rows="4" cols="22"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> Please list any witnesses (including passengers travelling in your vehicle) to the accident. (Include name, telephone number, address and where the witness was at the time of the accident. </div> <div class="listDiv"> <textarea name="txbWitness" rows="4" cols="45"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> If other vehicles were involved, have they made a claim against you? Please list name, address and telephone number of owner/driver, making and model of vehicle, registration number, any damage, and insurance held.</div> <div class="listDiv"> <textarea name="txbVehiclesInvolved" rows="4" cols="45"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> Was there any other property damaged? </div> <div class="listDiv"> <textarea name="txbPropertyDamaged" rows="4" cols="45"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> Please give particulars of damage and estimated cost of repairs (if known) including any repair estimates obtained. </div> <div class="listDiv"> <textarea name="txbParticularsOfDamage" rows="4" cols="45"></textarea></div> </div> <div class="checkboxItemField"> <label>Was there any un-repaired damage or rust in the vehicle before the accident?</label> <input type="radio" name="rbtnUnRepairedDamage" value="Yes" /> <input type="radio" name="rbtnUnRepairedDamage" value="No" /> </div> <div class="itemField"> <div class="listDiv2"> If yes, please describe. </div> <div class="listDiv"> <textarea name="txbUnRepairedDamage" rows="4" cols="45"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> Whom can we contact to make an appointment to inspect the vehicle? </div> <div class="listDiv"> <textarea name="txbAppointment" rows="4" cols="45"></textarea></div> </div> </fieldset> <fieldset> <legend>YOUR PRIVACY </legend> <div class="itemField"> We collect and receive your personal information in this claim form to consider your claim. We hold it. You have rights to access it, and correct it under the Privacy Act 1993. <br /> <br /> You must provide your relevant personal information to us to comply with the Claims Conditions of this policy. If you fail to do so, we may decline your claim. <br /> <br /> We obtain your authority below to transfer your relevant personal information to other members of the insurance industry (including Insurance Claims Register Limited), financially interested parties noted on your policy, and repairers. </div> </fieldset> <fieldset> <legend>YOUR DECLARATION </legend> <div class="itemField"> <span class="blueBolderText">I declare that: </span> <ul> <ol> 1 All information given to New India in connection with the claim is true. </ol> <ol> 2 No information relevant to the claim has been omitted. </ol> <ol> 3 I authorize: </ol> <ol> <ul> <ol> 3.1 New India to disclose this information to: </ol> <ol> <ul> <ol> 3.1.1 Other members of the insurance industry (including Insurance Claims Register Limited), and</ol> <ol> 3.1.2 Financially interested parties noted on the policy, and</ol> <ol> 3.1.3 Parties repairing or replacing your property. </ol> </ul> </ol> <ol> 3.2 The disclosure of my personal information held by any other parties to New India for the purpose of considering and administering the claim. </ol> </ul> </ol> </ul> </div> </fieldset> </div> </div>