Personal injury claim

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Please complete all fields below accurately and to the best of your knowledge. Please be aware making a fraudulent insurance claim is a criminal offence and the your details may be passed to the enforcement authorities. Any incorrect or insufficient information may lead to delays in dealing with your claim.

Fields with an asterisk (*) are required.

The Insured / Claimant

Insured’s name (name stated on insurance schedule)

Insured’s address

Contact name

Position

Telephone number

Email address

Is the Insured VAT registered?

If the person or organisation making this insurance claim (the Claimant) is not as named above, please provide the Claimant’s details below:

Claimant’s name

Claimant’s address

Contact name

Position

Telephone number

Email address

Is the Claimant VAT registered?

What is the relationship of the Claimant to the Insured?

Policy details

Policy number

Policy start date

Policy end date

Name of insurance broker

Insurance broker’s telephone number

Does the Claimant have the benefit of any other insurance that may be relevant to the subject matter of this claim, e.g. other Legal Expenses Insurance, Professional Indemnity, or Public Liability Insurance?

If yes, please provide details of the policy

Personal Injury claim details

Are you pursuing a legal action?

Have legal proceedings been issued?

Is there a deadline?

If yes, what is the deadline for?

What is the date of the deadline?

Name and address of the other side

Description of the dispute including value

Supporting documents

To enable your insurance claim to be assessed you must provide all correspondence and documents relevant to your legal case. Below is a list of the key documentation you are likely to have for your claim, which you must send to us if it exists in your case.

Please upload the necessary correspondence / documents or check the box if they do not exist.

Copy of your Policy Schedule

Correspondence between the you and the other party

Photos of the injury and the accident site

A copy of the doctors (or other medical professionals) report on your injury (if already obtained)

Select all files to upload at the same time. Click and hold down the control key (Ctrl) to select multiple files. (Do not exceed 10 MB) Choose file

Please send larger documents separately by email or alternatively you may send physical documents via the postal system.

Declaration

We were aware/not aware at the date of inception (or renewal) of this insurance that this claim, the details of which are set out above was liable to arise.

Please select one regarding the statement above:

We declare that all our statements within this claim form are true and complete.

We accept that making a fraudulent insurance claim is a criminal offence and the details may be passed to the enforcement authorities.

We request that Markel Legal Expenses Insurance deal with this matter in accordance with the terms and conditions of our Legal Expenses Insurance. We understand they will collect and use relevant information about us and any other individual’s details we provide to them, in respect of our insurance claim. This information may also be shared with third parties – but only in connection with the claim under the insurance cover. Full information on how Markel process your data can be found here.

We authorise Markel Legal Expenses Insurance to access and use, for the purpose of assessing this claim, the record(s) of our communications with the Legal Help Line. We also authorise Markel Legal Expenses Insurance to disclose information about this claim to the intermediary who arrange this insurance.

Check if you agree with all the statements above

Name

Position

Date

Suggested

Personal injury claim

The Insured / Claimant

Policy details

Personal Injury claim details

Supporting documents

Please upload the necessary correspondence / documents or check the box if they do not exist.

Declaration

Markel UK

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