New External Client Potential Claim Notification

Your Details
Incident Details
Vehicle Damage
Property Damage
Injury Details
Witnesses
Documents
Anti-Fraud and Declaration

Title

Forename

Surname

Company Name

Address Line 1

Address Line 2

Address Line 3

Town / City

County

Postcode

Date of Birth

National Insurance Number

Telephone Number

Email Address

Reference

Vehicle Involved?

Property Involved?

Injury?

Incident Date

Incident Time

Where did the incident happen?

Street Name

Village

Town

Postcode

Description of the incident - what happened?

Height and depth of the defect?

When did you become aware of the defect?

When did you report the defect to the Council?

Who did you report it to?

Visibility - Daylight

Visibility - Street Light

Weather

Police Reference Number

Date reported to police?

Why do you believe the Council are to blame for the incident?

Purpose and destination of the journey?

Speed of your vehicle at the time of accident (MPH)

Cause of the accident?

Council Vehicle Registration

Council Vehicle Make

Council Vehicle Model

Registration Number

Make

Model

Details of the damage

Has a claim been made to your insurers?

Registered Owner

Title

Forename

Surname

Address Line 1

Address Line 2

Address Line 3

Town / City

County

Postcode

Please provide a description of the property / losses being claimed

Do you have separate house insurance which would cover this claim?

Has a claim been made to your Insurers?

Injury

Injury Description

Hospital Attended

Date Attended Hospital

Hospital Name

Address Line 1

Address Line 2

Address Line 3

Town / City

County

Postcode

Witnesses Repeater

In order for your claim to be considered, please provide supporting documentation for the damage, loss or injury suffered.
The following are examples of what the Council will require:

Motor Claims

Photographs of Defect/Area
Photographs of vehicle damage
UK driving License
Certificate of Insurance
Valid MOT Certificate
Vehicle Registration Document
Copy receipts in support of any loss
Estimate for repairs

Injury and Property Damage Claims

Photographs of Defect/Area
Photographs of Injury
Photographs of any damage

Upload your supporting documents below

We have a responsibility to Council Tax payers to ensure that all claims received are legitimate.

All information provided on this form and obtained during the investigation of your claim may be used by Doncaster Council and other outside organisations, including, but not limited to, the Claims & Underwriting Exchange (CUE) and the Motor Insurers Anti-Fraud and Theft Register run by the Motor Insurers' Bureau (MIB) to detect dishonest claimants and take appropriate action against anyone attempting to defraud the Council. In addition, we may share your information with our legal representatives, contractors or outside bodies who may be involved with the defence of the claim.

I declare that the information I have given on this form, and any associated documentation, is true and complete. I am aware that I may be liable to prosecution if I have provided the Council with information that I know to be false.

I confirm the above statement is true