1st CENTRAL Step 1 of 7 14% To submit a claim please select your cover typeCover TypePrivate Vehicle Policy Reference*Policy Start Date* Date Format: DD slash MM slash YYYY Excess Protect Claim Limit*Have you previously made a claim under this Excess Policy?*YesNoOn receipt of this claim form by Business & Domestic Administration they will verify your certificate information. If you have previously claimed during this policy period they will calculate what indemnity excess still remains in force. Only the remaining balance will be claimable. Full Name* First Last Date of Birth* Date Format: DD slash MM slash YYYY Email* Contact Tel No.*Address* Street Address Address Line 2 City ZIP / Postal Code Vehicle Reg No*Vehicle Make*Vehicle Model*Applicable Excess*Type of Insurance*Fully ComprehensiveThird Party, Fire & TheftDescription of Use*Social Domestic & PleasureSocial, Domestic & Pleasure + CommutingBusiness Use Date of Incident Date Format: DD slash MM slash YYYY Time of Incident* : HH MM AM PM Are you claiming as the Policy Holder?*YesNoBreifly describe the incident details* Preferred Payment Method*BACS PersonalchequeThere are two methods of your claim being paid - please select your preferred method of payment. Please Note; By ticking this box you are providing us with your authority to communicate with your main policy insurer to further validate the claim where necessary and obtain the details of any third parties who we may approach, if applicable, for the subjugation of your claim under this Excess Protect policy. The information supplied to us by you may be held on our database and passed to other insurers for underwriting and claims purposes. When you tell us about an incident we will pass information relating to it to a database. We may search these databases when you have a claim to validate your claims history or that of any other person or property likely to be involved in the policy or claim. In order to prevent and detect fraud we may at any time: Share information about you with other organisations and public bodies including the Police; Check and/or file your details with fraud prevention agencies and databases, and if you give us false or inaccurate information and we suspect fraud, we will record this. You also agree for your insurance broker or branch to handle all items related to your claim on your behalf.I declare that, to the best of my knowledge and belief, the above statements made by me or on my behalf are true and complete and that I have not suppressed, misrepresented or misstated any material fact. I understand that if any of the information is found to be false or failure to disclose any material fact may invalidate my claim. * Agree If you do not wish to proceed with submitting your claim online or require an explanation regarding some aspect of this statement please call 03300 555 276.