Unique Claim Solutions Ltd

--------------------PERSONAL DETAILS-----------------------

-----------------------THIRD PARTY DETAILS-----------------------

Name: ..................................................................................................

Address: ..............................................................................................

............................................................. Postcode: ..............................

Telephone: ..........................................................................................

Date of Birth .......................................................................................

NI Number: .........................................................................................

Occupation: .........................................................................................

Employer's Name: ...............................................................................

Employer's Address: ...........................................................................

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VAT No. (if applicable) ......................................................................

Loss of Earnings Yes No

Average Weekly Income ...................................................................

Name: ............................................................................................................

Address: ........................................................................................................

............................................................. Postcode: ........................................

Telephone: ....................................................................................................

Make & Model: ..............................................................................................

Reg. No.: ........................................................................................................

Insurance Company: ...................................................................................

Address: ........................................................................................................

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Tel: ................................................................................................................

Policy No: .....................................................................................................

---------------------------POLICE DETAILS--------------------------

Name of Officer: ...........................................................................................

Police Station: ...............................................................................................

Telephone: ....................................................................................................

-------------------------ACCIDENT DETAILS-------------------------

Date & Time: ................................................................................................

Location: .......................................................................................................

Circumstances: .............................................................................................

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SKETCH OF ACCIDENT

UNIQUE CLAIM SOLUTIONS LTD
Lords House, 2nd Floor, Business Centre
665 North, Circular Road.
London NW2 7AX
Company Reg No: 06069603

Tel: 0208 453 7336 Fax: 0208 453 7337

I irrevocably instruct Unique Claim Solution accident assistance to act on my behalf in relation to my accident. I hearby authorise Unique Claim Solution accident accistance to appoint solicitors on my behalf. I agree Not to accept any payment in settlement of my claim from any other source then from solicitors or accident party as such an offer made. I also authorise the said solicitors to request and receive fromthe party's insurance, if appropriate, the Motor Insurance Bureau, all monies due to me by the way of damages arising from my accident on the ......................................... This also to include interim payment. I also authorise the said solicitors to make any settlement in respect of my car hire charges, injuries direct to Unique Claim Solution accident assistance.

Signed:.............................................. Date:....................................................

Print Name:.....................................................................................................

----------------------VEHICLE DETAILS------------------------

Make & Model: ...................................................................................

Reg. No.: ..............................................................................................

Insurance Company: ...........................................................................

Address: ..............................................................................................

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Policy No: ...........................................................................................

Is the Vehicle drive able? Yes No

Vehicle Location: ................................................................................

Engineer to be instructed: .................................................................

-------------------PERSONAL INJURIES-----------------------

Injuries suffered: ...............................................................................

Visited GP: ..........................................................................................

Name of G.P: .......................................................................................

G.P's Address: .....................................................................................

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Visited Hospital: Yes No

If Yes, Name & Address: ...................................................................

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--------------------PASSENGERS DETAILS---------------------

1 st. Name: ..........................................................................................

1 st. Address: .....................................................................................

................................................................ Tel: .....................................

2 nd. Name: ........................................................................................

2 nd. Address: ....................................................................................

................................................................ Tel: .....................................

3 rd. Name: .........................................................................................

3 rd. Address: .....................................................................................

................................................................ Tel: .....................................

----------------------WITNESS DETAILS-----------------------

Name: .................................................................................................

Address: .............................................................................................

...................................................... Postcode: .....................................

Telephone: .........................................................................................