Insurance claim form

Before you complete this form, please take the time to read the claims process as it explains information you should be aware of:
If you have any difficulty in completing this form please contact the issuing office on 01753 552288 or email insurance@slough.gov.uk
 

Personal details

 

Particulars and location of incident

Date: *
Date:
Time: *
Time:
Or
Please use landmarks, eg, distance from road junction, lamp post, telegraph pole, house name/number, etc.
 

Witnesses

 

The police

 

The Highways Department

 

Motor vehicle damage

 

Personal injury

 

Negligence

 

Photographic evidence

Photos of the incident's location may assist our investigations.
 

Sketch of the incident site

Please draw a sketch of the incident site, include any landmarks, road names, etc as appropriate and email it to insurance@slough.gov.uk or post it to: Risk Management and Insurance Services, St Martins Place, 51 Bath Road, Slough, SL1 3UF.
Once you have submitted this form you will get a reference number. Please include this reference number when you send your sketch.

The incident

 

Declaration

Date:
Date:
 

Please note:

The information you provide may be shared with other appropriate council departments and outside agencies for the registered purposes under the Data Protection Act 1998.
The council is under a general duty to protect the public funds they handle and may use the information you have provided to prevent and detect fraud. Therefore the information you provide may be checked against other council records. The council may also share this information, for the same purposes, with other organisations that handle public funds.
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