Claims Form - Impact Assist Ltd

To report your claim online, please complete and submit the form below.

If you would prefer to view as a pdf version that you can print off, please download Download PDF Form.

Should you require clarification on any matter please contact us free on 0800 0430907 or e-mail enquiries@impactassist.co.uk.

Your Personal & Insurance Details:
* Full Name:
* Address line 1:	Address line 2:	Address line 3:
Town:	County:	* Postcode:
Date of Birth:
Telephone: (Home):	(Mobile):	(Work):
Email:
Insurance Broker Name:	Insurance Company Name:
Policy Number:	Policy Cover:

Your Vehicle Details:

Vehicle (Make):

Model:

Vehicle Registration:

Is your vehicle driveable:
Yes No

Will you require a replacement vehicle:
Yes No

Personal Injury
Did you or your passengers suffer any injuries? Yes No
Details of injured occupants;
1. Full Name:	1. Telephone:
2. Full Name:	2. Telephone:
3. Full Name:	3. Telephone:

*indicates required form fields

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