Claims Notification Form1. Personal InformationFirst NameLast NameAddress Line 1Address Line 2CityPost CodeCountrySelect CountryUnited Kingdom (UK)Email2. Details of the IncidentDate & Time of the IncidentLocation of the Incident, 3. Description of the PotholeProvide as much detail of the pothole as possible such as size, depth, exposed rods etc Details of the PotholeWas the pothole the direct cause of the damage to your vehicle? Yes NoFILE UPLOAD - Images of the pothole and surrounding areas are essential. Include at least one wide shot and one close up shot with measurements if possible, you can use your foot to demonstrate the size 4. Vehicle Damage DetailsType of Vehicle- Select -CarVanMotorbikeType of Damage Body Damage Tyre Damage Wheel Damage Suspension DamageDamage DescriptionFILE UPLOAD images of the damage to your vehicle5. Repair CostsRepair CostsFILE UPLOAD of repair costs, repair bills, invoices etc6. Supporting Evidenceeg breakdown report, recovery report, mechanic reports, witness statements etcFILE UPLOAD7. Road Maintenance InformationHave you reported the pothole? Yes NoIf yes, please provide details of the prior report eg date, reference number etc8. Confirmation & DeclarationAcknowledgement I confirm that the information I have provided is accurate to the best of my knowledgePrivacy Consent I consent to the collection and use of my data as per the website's privacy policyTerms I agree to the terms and conditions as per the website's terms Submit Form
