Claim notification
| Published date | 21 March 2018 |
Please tick here if you are not legally represented?If you are not legally represented please put your details in the
claimant’s representative section.
1
Claimant’s representative - contact details
Name
Address
Contact name
Telephone number
E-mail address
Reference number
Defendant’s details
Defendant’s name
Defendant’s address*
Defendant’s vehicle registration number
Policy number reference
Insurer name
Date sent/ /
RTA1 - Claim notication form (04.13)
Postcode
Claim notication form (RTA1)
Low value personal injury claims in
road trac accidents (£1,000 - £25,000)
Before lling in this form you are encouraged to seek independent legal advice.
Postcode
Items marked with (*) are optional and the claimant must make a reasonable attempt to complete those boxes.
All other boxes on the form are mandatory and must be completed before being sent.
What is the value of your claim?up to £10,000up to £25,000
2
Section B— Injury and medical details
2
1.1 What type of injury was suered?Soft tissueBone injuryWhiplash
Other
Please provide a further brief description of the
injury sustained as a result of the incident
1.2 Has the claimant had to take any time o work as
a result of the injury?Yes No
1.3 Is the claimant still o work?Yes No
If No, how many days in total was the
claimant o work?
1.4 Has the claimant sought any medical attention?Yes No
If Yes, on what date did they rst do so?/ /
Section A— Claimant’s details
Mr. Mrs. Ms.
Miss Other
Claimant’s name
Address
Date of birth
/ /
Occupation
Claimant’s vehicle registration number (if applicable)
Accident date
/ /
Postcode
Is this a child claim?Yes No
National Insurance number
If the claimant does not have a National Insurance
number, please explain why
this section continu es over the page
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