Claim Form

Personal Details

Incident Details

Set Exact defect and incident Location on Map

Please note that claims without precise location information cannot be investigated

Solicitor Details

Claims for Injury

Further Information

Do you wish to add a Witness?

Attachments

Please attach the following mandatory evidence and any optional evidence you would like to include to support your claim.

Mandatory

Photos of the damage to your vehicle/property*

For personal property, the original purchase receipt or other proof of purchase should be provided to support ownership and financial loss*

Optional

Photos of the defect where it is safe to do so

If your insurer is not dealing with repairs or replacement, please attach two independent estimates/quotes or receipts for the repairs of your vehicle/property

Any other Attachment

Data Protection

Please click the following link to read our privacy notice. https://www.bristol.gov.uk/data-protection-foi/fraud-prevention-and-detection

Section 6 - Declaration

I certify that the information I have given is true to the best of my knowledge and belief. Please note any claims made which are found to be untrue will be investigated as potential fraud and referral may be made to the police.