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CLAIMS TRACKING Customer Login
User
Pass
Submit
Welcome to the
Allianz Claims
Tracking System.
Please enter your User ID and Password for access.
On-line Claims Notification Form
Please note that fields marked with asterisk (*) are mandatory.
Are you the?
Please select:
Policyholder
Broker
Driver
Fleet Manager
Accident Management Company
Section 1. Claim Details
Date of Incident * (dd/mm/yyyy)
Time of Incident
Hour
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Minutes
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Name of Informer *
Informer Telephone * (01123 456789)
Informer Email Address *
Confirm Informer Email Address *
Is the policyholder VAT registered?
Please select:
Yes
No
Partially
Policy Number * (PX 12345678)
Policy Section
Please select:
Agricultural Vehicles
Business Interruption
Coach and Minibus
Commercial Legal Expenses
Commercial Vehicles Hire and Reward
Commercial vehicles Own Goods
Conversion
Directors and Officers Cover
Employers Liability
Engineering
Fidelity Guarantee
Hire Car - Private and Public
Material Damage
Motorcycle
MOT Loss of Licence
Motor Vehicle Road Risks
Personal Accident
Private Cars
Public and Products Liability
Self Drive Vehicle Hire
Special Types and Plant
Terrorism-Business Interruption
Terrorism-Material Damage
Trade Plates
Trailer
Section 2. Driver & Incident Details
Driver Title
Please select:
Mr
Ms
Mrs
Professor
Doctor
Other
Driver Name *
Driver Address *
Driver Postcode *
Driver Telephone Number * (Home)
Driver Telephone Number (Mobile)
Driver/Policyholder Email Address
Confirm Email Address
Incident Description *
Speed of Vehicle (mph)
Who do you consider responsible ? *
Please select:
Driver
Third Party
Both Driver and Third Party
No Other Party Involved
Unknown
Location of Incident
Drivers Date of Birth *
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
January
February
March
April
May
June
July
August
September
October
November
December
Driver Occupation *
Has driver been breathalysed?
Please select:
Yes
No
Don't Know
Driver Injury
Please select:
Yes please give details below
No
Type of Licence
Please select:
Full UK Licence
HGV Licence
International/Foreign Licence
None
Provisional Licence
Inexperienced, Full UK lesss than 1 year
Cost Centre (If applicable)
Employee Number (If applicable)
Division/Depot
Any motor convictions in past 5 years?
Please select:
Yes please give details below
No
Driver Disabilities Reportable to DVLA
Please select:
Yes please give details below
No
Any pending prosecutions?
Please select:
Yes please give details below
No
Section 3. Vehicle Details
Registration Number *
Make/Model *
Colour
Approximate Mileage
Purpose of Journey *
Please select:
Carriage of own goods
Carriage of goods for hire and reward
Carriage of passenger for hire and reward
Other business use
Self Drive Hire - Full
Self Drive Hire - Contingency
Social, Domestic and Pleasure
Unknown
Is insured the Registered Owner?
Please select:
No please give details below
Yes
Is Vehicle on Finance/HP
Please select:
Yes please provide finance details
No
Finance/HP Company Name
Finance/HP Account Number
Finance/HP Company Address
Finance/HP Company Postcode
Any previous damage to vehicle
Please select:
Yes please give details below
No
Vehicle damaged as a result of incident *
Please select:
Yes please give details below
No
Damage to vehicle including area
Is vehicle driveable
Please select:
Yes
No
Current Vehicle Location *
Repairers required
Please select:
Allianz Approved Repairer
Own Repairer
Not required
Other
Section 4. Third Party Details (if applicable)
Please select:
Yes
No
Don't Know
Third Party Title
Please select:
Mr
Ms
Mrs
Miss
Professor
Doctor
Other
Third Party Name
Third Party Address
Third Party Postcode
Third Party Telephone Number (Home)
Third Party Telephone Number (Mobile)
Third Party Incident Description
Third Party Insurer Name
Third Party Insurer Address
Third Party Insurer Postcode
Third Party Insurer Telephone
Third Party Insurer Policy No.
Third Party Registration No.
Manufacturer/Model
Colour
Any existing damage to TP vehicle
Please select:
Yes please give details below
No
Third Party Vehicle Damaged as Result
Please select:
Yes please enter details below
No
Third Party Breathalysed?
Please select:
Yes
No
Third Party Injured
Please select:
Yes please give details below
No
Add Another Third Party
Please select:
Yes
No
Second Third Party Title
Please select:
Mr
Ms
Mrs
Miss
Professor
Doctor
Other
Second Third Party Name
Second Third Party Address
Second Third Party Postcode
Second Third Party Tel Number (Home)
Second Third Party Tel Number (Mobile)
Second Third Party Incident Description
Second Third Party Insurer Name
Second Third Party Insurer Address
Second Third Party Insurer Postcode
Second Third Party Insurer Telephone
Second Third Party Insurer Policy No.
Second Third Party Registration No.
Manufacturer/Model
Colour
Any existing damage to TP vehicle
Please select:
Yes please give details below
No
Third Party Vehicle Damaged as Result
Please select:
Yes please enter details below
No
Third Party Breathalysed?
Please select:
Yes
No
Third Party Injured
Please select:
Yes please give details below
No
Section 5. Passengers
Please select:
Yes
No
Don't Know
Which Vehicle
Passenger One Gender
Please select:
Male
Female
Passenger One Name
Passenger One Address
Passenger One Postcode
Passenger One Telephone (Home)
Passenger One Telephone (Mobile)
Passenger One Injured ?
Please select:
Yes please enter details below
No
Add Another Passenger
Please select:
Second passenger
No other passengers on board
Which Vehicle
Passenger Two Gender
Please select:
Male
Female
Passenger Two Name
Passenger Two Address
Passenger Two Postcode
Passenger Two Telephone (Home)
Passenger Two Telephone (Mobile)
Passenger Two Injured ?
Please select:
Yes please enter details below
No
Add Another Passenger
Please select:
Third passenger
No other passengers on board
Which Vehicle
Passenger Three Gender
Please select:
Male
Female
Passenger Three Name
Passenger Three Address
Passenger Three Postcode
Passenger Three Telephone (Home)
Passenger Three Telephone (Mobile)
Passenger Three Injured ?
Please select:
Yes please enter details below
No
Add Another Passenger
Please select:
Fourth passenger
No other passengers on board
Which Vehicle
Passenger Four Gender
Please select:
Male
Female
Passenger Four Name
Passenger Four Address
Passenger Four Postcode
Passenger Four Telephone (Home)
Passenger Four Telephone (Mobile)
Passenger Four Injured ?
Please select:
Yes please enter details below
No
Section 6. Police Details
Please select:
Yes
No
Don't Know
Officer Name
Officer Badge Number
Police Station
Police Station Telephone
Incident/Crime Reference
Date Reported (dd/mm/yyyy)
Time Reported
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Minutes
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
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35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Section 7. Witness Details
Please select:
Yes
No
Don't Know
Witness Gender
Please select:
Male
Female
Witness Name
Witness Address
Witness Postcode
Witness Telephone (Home)
Witness Telephone (Mobile)
Was the witness know to you before?
Please select:
Yes please enter details below
No
Add Another Witness
Please select:
Yes
No
Second Witness Gender
Please select:
Male
Female
Second Witness Name
Second Witness Address
Second Witness Postcode
Second Witness Telephone (Home)
Second Witness Telephone (Mobile)
Was the witness know to you before?
Please select:
Yes please enter details below
No
Section 8. Status Details
Is this form for information only (No repairs to either vehicle)
Please select:
Yes please enter details below
No
Any Other Information (Relevant to Claim)
Have you received any correspondence from a TP on the Claim?
Please select:
Yes
No