:@0.120984:0.032497:0.125175:0.032497:0.125175:0.019384:0.120984:0.019384:0.004191 :@0.120984:0.050884:0.125175:0.050884:0.125175:0.037771:0.120984:0.037771:0.004191 Injury claims only - please describe any personal injury that you have sustained. :@0.120984:0.066847:0.736621:0.066847:0.736621:0.053734:0.120984:0.053734:0.005026:0.009884:0.004822:0.009884:0.006454:0.008846:0.004024:0.007844:0.004618:0.009068:0.004432:0.015077:0.007307:0.004191:0.009921:0.009884:0.004618:0.008846:0.004333:0.005442:0.004233:0.009884:0.004618:0.009272:0.009068:0.007436:0.009272:0.004024:0.009884:0.009272:0.007436:0.007844:0.006454:0.004618:0.009884:0.009272:0.004191:0.009161:0.009829:0.008846:0.004191:0.009959:0.009235:0.006639:0.007436:0.009884:0.009884:0.009068:0.004618:0.004024:0.004618:0.009884:0.004822:0.009680:0.006639:0.008846:0.004191:0.006472:0.009884:0.009068:0.006250:0.004191:0.008901:0.009884:0.009884:0.004191:0.009959:0.009031:0.008846:0.009272:0.004359:0.007436:0.009884:0.007436:0.006435:0.009087:0.004618:0.009884:0.009272:0.009680:0.004880:0.004191 :@0.786249:0.066847:0.790440:0.066847:0.790440:0.053734:0.786249:0.053734:0.004191 :@0.120984:0.083381:0.125175:0.083381:0.125175:0.070268:0.120984:0.070268:0.004191 :@0.120984:0.218524:0.125175:0.218524:0.125175:0.205411:0.120984:0.205411:0.004191 Please detail the items and amounts that you are claiming for and the age of the items :@0.120984:0.248741:0.788022:0.248741:0.788022:0.235628:0.120984:0.235628:0.009866:0.004636:0.009272:0.009068:0.007436:0.009272:0.004191:0.009959:0.009235:0.006435:0.009087:0.004618:0.004432:0.004191:0.006472:0.009884:0.009272:0.004191:0.004469:0.006435:0.009328:0.015077:0.007251:0.004191:0.009161:0.009829:0.009884:0.004191:0.009161:0.015077:0.009866:0.009884:0.009884:0.006435:0.007455:0.004191:0.006472:0.009884:0.009068:0.006435:0.004228:0.008846:0.009884:0.009884:0.004191:0.009161:0.006583:0.009328:0.003987:0.007659:0.004618:0.009068:0.004618:0.015077:0.004655:0.009680:0.008846:0.004191:0.005860:0.009903:0.006639:0.004191:0.009161:0.009829:0.009884:0.004191:0.006472:0.009884:0.009272:0.004191:0.009161:0.008790:0.009105:0.004191:0.009921:0.005860:0.004191:0.006435:0.009717:0.009272:0.004191:0.004655:0.006435:0.009328:0.014873:0.007590:0.004191 DESCRIPTION OF :@0.120984:0.265275:0.250976:0.265275:0.250976:0.252162:0.120984:0.252162:0.011479:0.009050:0.008512:0.009884:0.010070:0.004414:0.009662:0.009031:0.004673:0.012277:0.011930:0.004031:0.012277:0.008512:0.004191 ITEM :@0.120984:0.281238:0.163675:0.281238:0.163675:0.268125:0.120984:0.268125:0.004673:0.009031:0.009050:0.015746:0.004191 DATE OF :@0.272962:0.265275:0.342282:0.265275:0.342282:0.252162:0.272962:0.252162:0.011479:0.010737:0.009031:0.009050:0.004043:0.012277:0.008512:0.004191 PURCHASE :@0.272962:0.281238:0.358236:0.281238:0.358236:0.268125:0.272962:0.268125:0.009662:0.011906:0.010070:0.009884:0.011479:0.010737:0.008419:0.008925:0.004191 WHERE :@0.380048:0.265275:0.440466:0.265275:0.440466:0.252162:0.380048:0.252162:0.016505:0.011553:0.009050:0.010070:0.009050:0.004191 PURCHASED :@0.380048:0.281238:0.476559:0.281238:0.476559:0.268125:0.380048:0.268125:0.009662:0.011906:0.010070:0.009884:0.011479:0.010737:0.008419:0.008864:0.011298:0.004191 MAKE/MODEL REPLACEMENT ESTIMATE OR :@0.499177:0.265275:0.867425:0.265275:0.867425:0.252162:0.499177:0.252162:0.015911:0.010737:0.009643:0.008846:0.007232:0.015726:0.012277:0.011312:0.009050:0.007863:0.004191:0.018267:0.010070:0.009050:0.009495:0.007844:0.010737:0.009829:0.009050:0.015744:0.009050:0.011906:0.009031:0.004191:0.014824:0.009050:0.008512:0.009031:0.004673:0.015856:0.010737:0.009031:0.008901:0.004191:0.012314:0.009884:0.004191 NO. :@0.499177:0.281238:0.532193:0.281238:0.532193:0.268125:0.499177:0.268125:0.011887:0.012277:0.004661:0.004191 COST :@0.630232:0.281238:0.673932:0.281238:0.673932:0.268125:0.630232:0.268125:0.009884:0.012277:0.008512:0.008835:0.004191 INVOICE :@0.761053:0.281238:0.828110:0.281238:0.828110:0.268125:0.761053:0.268125:0.004673:0.011850:0.010515:0.012277:0.004673:0.009829:0.009050:0.004191 ATTACHED :@0.761053:0.297202:0.846488:0.297202:0.846488:0.284089:0.761053:0.284089:0.010737:0.009031:0.009031:0.010737:0.009884:0.011461:0.009050:0.011312:0.004191 (YES/NO) :@0.761053:0.313201:0.834232:0.313201:0.834232:0.300088:0.761053:0.300088:0.005619:0.009068:0.009050:0.008512:0.007214:0.011887:0.012091:0.005547:0.004191 :@0.120984:0.329734:0.125175:0.329734:0.125175:0.316622:0.120984:0.316622:0.004191 :@0.272962:0.329734:0.277153:0.329734:0.277153:0.316622:0.272962:0.316622:0.004191 :@0.380048:0.329734:0.384239:0.329734:0.384239:0.316622:0.380048:0.316622:0.004191 :@0.499177:0.329734:0.503368:0.329734:0.503368:0.316622:0.499177:0.316622:0.004191 :@0.630232:0.329734:0.634424:0.329734:0.634424:0.316622:0.630232:0.316622:0.004191 :@0.761053:0.329734:0.765244:0.329734:0.765244:0.316622:0.761053:0.316622:0.004191 :@0.120984:0.365652:0.125175:0.365652:0.125175:0.352539:0.120984:0.352539:0.004191 :@0.272962:0.365652:0.277153:0.365652:0.277153:0.352539:0.272962:0.352539:0.004191 :@0.380048:0.365652:0.384239:0.365652:0.384239:0.352539:0.380048:0.352539:0.004191 :@0.499177:0.365652:0.503368:0.365652:0.503368:0.352539:0.499177:0.352539:0.004191 :@0.630232:0.365652:0.634424:0.365652:0.634424:0.352539:0.630232:0.352539:0.004191 :@0.761053:0.365652:0.765244:0.365652:0.765244:0.352539:0.761053:0.352539:0.004191 :@0.120984:0.404991:0.125175:0.404991:0.125175:0.391878:0.120984:0.391878:0.004191 :@0.272962:0.404991:0.277153:0.404991:0.277153:0.391878:0.272962:0.391878:0.004191 :@0.380048:0.404991:0.384239:0.404991:0.384239:0.391878:0.380048:0.391878:0.004191 :@0.499177:0.404991:0.503368:0.404991:0.503368:0.391878:0.499177:0.391878:0.004191 :@0.630232:0.404991:0.634424:0.404991:0.634424:0.391878:0.630232:0.391878:0.004191 :@0.761053:0.404991:0.765244:0.404991:0.765244:0.391878:0.761053:0.391878:0.004191 :@0.120984:0.442049:0.125175:0.442049:0.125175:0.428936:0.120984:0.428936:0.004191 Vehicle damage claims only :@0.120984:0.472266:0.336617:0.472266:0.336617:0.459153:0.120984:0.459153:0.010886:0.009272:0.009884:0.004618:0.007844:0.004618:0.009272:0.004191:0.009959:0.009031:0.015077:0.009161:0.008790:0.009105:0.004191:0.007752:0.004562:0.009087:0.004618:0.014910:0.007436:0.004191:0.009921:0.009884:0.004432:0.008750:0.004191 Please describe any damage to your vehicle :@0.120984:0.488799:0.451967:0.488799:0.451967:0.475687:0.120984:0.475687:0.009662:0.004265:0.009235:0.008883:0.007047:0.009235:0.004247:0.009680:0.009235:0.007251:0.007696:0.006472:0.004265:0.009625:0.009235:0.004247:0.008883:0.009662:0.008271:0.004191:0.009736:0.008883:0.014873:0.008883:0.008456:0.009235:0.004247:0.006045:0.009866:0.004191:0.008308:0.009866:0.009680:0.006472:0.004006:0.008456:0.009235:0.009736:0.004210:0.007844:0.004043:0.009234:0.004191 _____________________________________________________________________________ :@0.120984:0.504763:0.833627:0.504763:0.833627:0.491650:0.120984:0.491650:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009653:0.004191 _____________________________________________________________________________ :@0.120984:0.520608:0.833627:0.520608:0.833627:0.507495:0.120984:0.507495:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009653:0.004191 _____________________________________________________________________________ :@0.120984:0.536571:0.833627:0.536571:0.833627:0.523458:0.120984:0.523458:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009489:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009418:0.004191 :@0.120984:0.552535:0.125175:0.552535:0.125175:0.539422:0.120984:0.539422:0.004191 What speed were you travelling at the time of the incident __________________________mph :@0.120984:0.568498:0.842698:0.568498:0.842698:0.555385:0.120984:0.555385:0.016505:0.009736:0.008883:0.006212:0.004191:0.007251:0.009736:0.009050:0.009235:0.009736:0.004191:0.013130:0.009235:0.006472:0.009235:0.004080:0.008271:0.009866:0.009680:0.004191:0.006268:0.006472:0.008642:0.008271:0.009235:0.004265:0.004265:0.004210:0.009680:0.008660:0.004191:0.008883:0.006250:0.004191:0.006268:0.009680:0.009068:0.004191:0.006268:0.004024:0.014891:0.009235:0.004061:0.009866:0.005656:0.004024:0.006212:0.009736:0.009235:0.004191:0.004265:0.009736:0.007622:0.004265:0.009643:0.009235:0.009736:0.006212:0.004191:0.009309:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009105:0.014891:0.009680:0.009915:0.004191 :@0.120984:0.584462:0.125175:0.584462:0.125175:0.571349:0.120984:0.571349:0.004191 Vehicle registration number __________________ Make/Model _________________________ :@0.120984:0.600425:0.845520:0.600425:0.845520:0.587312:0.120984:0.587312:0.010515:0.009235:0.009680:0.004265:0.007844:0.004265:0.009235:0.004191:0.006472:0.009235:0.008734:0.004265:0.007010:0.006212:0.006472:0.008883:0.006212:0.004061:0.009866:0.009680:0.004191:0.009736:0.009662:0.014891:0.009476:0.009068:0.006472:0.004191:0.009272:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.004191:0.004080:0.015726:0.008883:0.008438:0.009235:0.007158:0.015670:0.009866:0.009680:0.009235:0.004265:0.004191:0.009124:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009511:0.004191 :@0.120984:0.616389:0.125175:0.616389:0.125175:0.603276:0.120984:0.603276:0.004191 Are you the registered owner? :@0.120984:0.632352:0.367127:0.632352:0.367127:0.619239:0.120984:0.619239:0.010737:0.006398:0.009235:0.004247:0.008271:0.009866:0.009680:0.004191:0.006268:0.009680:0.009068:0.004191:0.006472:0.009272:0.008660:0.004265:0.007251:0.006027:0.009235:0.006472:0.009235:0.009736:0.004024:0.009866:0.013259:0.009513:0.009235:0.006472:0.008660:0.004191:0.004080:0.004191:0.004191 Yes / No:@0.367349:0.632352:0.432088:0.632352:0.432088:0.619239:0.367349:0.619239:0.009643:0.009105:0.007436:0.004024:0.008048:0.004191:0.012314:0.009977 :@0.432053:0.632352:0.444460:0.632352:0.444460:0.619239:0.432053:0.619239:0.004024:0.004191:0.004191 delete as applicable :@0.444551:0.632352:0.596931:0.632352:0.596931:0.619239:0.444551:0.619239:0.009476:0.008864:0.004265:0.008642:0.006212:0.008864:0.004247:0.009476:0.007047:0.004191:0.009532:0.009458:0.009476:0.004265:0.004210:0.007715:0.009421:0.009476:0.004265:0.009086:0.004191 Is the vehicle available for inspection? :@0.120984:0.648316:0.418909:0.648316:0.418909:0.635203:0.120984:0.635203:0.004673:0.007251:0.004191:0.006212:0.009736:0.009235:0.004061:0.008456:0.009235:0.009736:0.004210:0.007844:0.004265:0.009050:0.004191:0.008883:0.008289:0.008883:0.004265:0.004191:0.008883:0.009662:0.004265:0.009235:0.004191:0.005489:0.009866:0.006472:0.004191:0.004043:0.009680:0.007251:0.009736:0.009235:0.007844:0.006212:0.004265:0.009866:0.009476:0.008642:0.004338:0.004031:0.004191 Yes / No:@0.418951:0.648316:0.483709:0.648316:0.483709:0.635203:0.418951:0.635203:0.009643:0.009328:0.007399:0.004061:0.008048:0.004024:0.012277:0.009977 :@0.483656:0.648316:0.496313:0.648316:0.496313:0.635203:0.483656:0.635203:0.004233:0.004233:0.004191 delete as applicable:@0.496355:0.648316:0.644323:0.648316:0.644323:0.635203:0.496355:0.635203:0.009272:0.008864:0.004265:0.008642:0.006212:0.008864:0.004247:0.009476:0.007214:0.004265:0.009476:0.009476:0.009476:0.004265:0.004210:0.007715:0.009421:0.009476:0.004265:0.008864 :@0.644141:0.648316:0.648332:0.648316:0.648332:0.635203:0.644141:0.635203:0.004191 :@0.120984:0.664849:0.125175:0.664849:0.125175:0.651737:0.120984:0.651737:0.004191 :@0.120984:0.695066:0.125175:0.695066:0.125175:0.681953:0.120984:0.681953:0.004191 :@0.120984:0.725318:0.125175:0.725318:0.125175:0.712205:0.120984:0.712205:0.004191 INSURANCE :@0.120984:0.743562:0.215674:0.743562:0.215674:0.730449:0.120984:0.730449:0.005026:0.012091:0.008846:0.012110:0.010274:0.011238:0.012147:0.009866:0.008903:0.004191 Do you have separate house contents/vehicle insurance which would cover this loss? :@0.120984:0.760096:0.763430:0.760096:0.763430:0.746983:0.120984:0.746983:0.011479:0.009680:0.004191:0.008308:0.009866:0.009680:0.004191:0.009736:0.008883:0.008234:0.009235:0.004247:0.007047:0.009235:0.009736:0.008883:0.006416:0.008883:0.006212:0.009087:0.004191:0.009736:0.009847:0.009680:0.007047:0.009235:0.004247:0.007659:0.009866:0.009680:0.006212:0.009291:0.009680:0.006212:0.007237:0.007047:0.008456:0.009235:0.009736:0.004210:0.007844:0.004265:0.009073:0.004233:0.004265:0.009643:0.007251:0.009736:0.006398:0.008883:0.009662:0.007844:0.009235:0.004265:0.013259:0.009736:0.004265:0.007844:0.009439:0.004191:0.013148:0.009866:0.009680:0.004265:0.009643:0.004191:0.007881:0.009680:0.008456:0.009235:0.006287:0.004191:0.006268:0.009680:0.004265:0.007251:0.004309:0.004024:0.009866:0.007251:0.007281:0.008466:0.004191 Yes / No :@0.120984:0.776059:0.202555:0.776059:0.202555:0.762947:0.120984:0.762947:0.009643:0.009328:0.007399:0.004061:0.008048:0.004191:0.012314:0.009915:0.004024:0.004191:0.004265:0.004191 delete as applicable :@0.202614:0.776059:0.354809:0.776059:0.354809:0.762947:0.202614:0.762947:0.009476:0.008864:0.004043:0.008864:0.006212:0.008864:0.004265:0.009476:0.007047:0.004191:0.009532:0.009458:0.009476:0.004265:0.004210:0.007715:0.009421:0.009476:0.004265:0.008882:0.004191 :@0.120984:0.792023:0.125175:0.792023:0.125175:0.778910:0.120984:0.778910:0.004191 If yes, have you made a claim to your Insurers? :@0.120984:0.807987:0.481158:0.807987:0.481158:0.794874:0.120984:0.794874:0.004673:0.005656:0.004191:0.008438:0.009235:0.007251:0.004469:0.004191:0.009736:0.008883:0.008234:0.009235:0.004247:0.008271:0.009866:0.009680:0.004024:0.014891:0.008883:0.009662:0.009235:0.004061:0.008883:0.004191:0.007844:0.004265:0.008883:0.004024:0.014891:0.004191:0.006083:0.009866:0.004024:0.008456:0.009866:0.009680:0.006250:0.004191:0.004673:0.009680:0.007251:0.009736:0.006398:0.009235:0.006472:0.007251:0.008493:0.004191:0.004191 Yes / No :@0.481439:0.807987:0.633808:0.807987:0.633808:0.794874:0.481439:0.794874:0.004024:0.004191:0.004265:0.004191:0.004080:0.004191:0.004265:0.004191:0.004094:0.004191:0.004265:0.004024:0.004191:0.004265:0.004260:0.009643:0.009328:0.007232:0.004191:0.007900:0.004191:0.012314:0.009939:0.004024:0.004191:0.004265:0.004191:0.004080:0.004191 delete as applicable:@0.633861:0.807987:0.781847:0.807987:0.781847:0.794874:0.633861:0.794874:0.009476:0.008864:0.004265:0.008864:0.006212:0.008679:0.004191:0.009532:0.007214:0.004247:0.009476:0.009476:0.009272:0.004265:0.004210:0.007715:0.009421:0.009476:0.004265:0.008864 :@0.781815:0.807987:0.786006:0.807987:0.786006:0.794874:0.781815:0.794874:0.004191 :@0.120984:0.830364:0.125175:0.830364:0.125175:0.817251:0.120984:0.817251:0.004191 :@0.120984:0.848750:0.125175:0.848750:0.125175:0.835638:0.120984:0.835638:0.004191 :@0.120984:0.864714:0.125175:0.864714:0.125175:0.851601:0.120984:0.851601:0.004191 :@0.120984:0.880677:0.125175:0.880677:0.125175:0.867565:0.120984:0.867565:0.004191 :@0.120984:0.896636:0.125175:0.896636:0.125175:0.883523:0.120984:0.883523:0.004191 :@0.120984:0.912600:0.125175:0.912600:0.125175:0.899487:0.120984:0.899487:0.004191