Churchill Motor Claims
PO Box 1079
BROMLEY
BR1 9QS
Mr A Khan
51 Oakleigh Drive
Orton Longueville
PETERBOROUGH
Cambridgeshire
PE2 7BB
Tel: 03458776123
Fax: 0345 835 4003
www.churchill.com
Dear Mr Khan,
Date:
10 August 2022
Please quote our
reference number on
all correspondence
Re: Your motor claim
We refer to your recent claim and enclose the Motor Accident Report Forms for you to complete
and return to us at the above address.
Please ensure the enclosed are completed accurately with all available information.
Our reference:
201564648/2
We look forward to receiving your completed forms as soon as possible.
Incident date:
11 October 2021
Should you have any queries or require any additional information, please contact Tammy Young
directly on 03458776123.
Yours sincerely
Page 1 of 1
Churchill insurance policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds, LS1 4AZ.
Registered in England and Wales No.1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the
Financial Conduct Authority and the Prudential Regulation Authority. Calls may be recorded.
MOTOR ACCIDENT REPORT FORM
Please complete this document as fully as possible and return to us via post or email.
PLEASE NOTE:
1
2
If you want to seek recovery for any of your losses or injuries then you must notify us of this as a matter of
urgency - failure to do so may result in you forfeiting your right to seek recovery of these losses
If you give any information that is or might be false, or if you omit to answer the questions asked fully, then this
may adversely affect the outcome of your claim. Also, if you dishonestly give any information that you know is or
might be false, then you may be prosecuted.
Policyholder's name: Mr Adnan Khan
Claim Number: 201564648
Reg. No:
F2FAR
Accident Location
Address Line 1: 51 oakleigh drive
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Address Line 2:
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Address Line 3:
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City: Peterborough
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County: cambridgeshire
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Post Code: pe2 7bb
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Country: UK
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Date of accident: 11 october 2021
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Time of accident: 8:50pm
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Churchill insurance policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds, LS1 4AZ. Registered
Page 1 of 12 in
England and Wales No.1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Calls may be recorded.
Claim Number: 201564648
Road conditions at time of accident (e.g. wet, dry, icy etc.): Dry
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Visibility at time of accident (e.g. daylight, dark, dusk etc.): Dark but clear and well light area
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If the visibility was poor, were your vehicle's lights on:
Full Lights were on
full lights
/
side lights
/
fog lights
/
no lights
Speed limit in place at scene of accident: 30
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How many vehicles were involved in the accident? 2
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Were any pedestrians involved in the accident? No
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Did the Police attend?
YES
/
NO
If YES, which officer/station is dealing with the accident?
No, I had called them and they had told me to drive home if possible
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Did an ambulance attend? YES / NO
Police reference number:
No
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Your Vehicle (Vehicle 1)
Driver Details
Title: mr
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First Name: adnan
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Surname: khan
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Address Line 1: 51 oakleigh drive
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Address Line 2:
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Address Line 3:
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City: Peterborough
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County: cambridgshire
Page 2 of 12
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Post Code: pe2 7bb
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Country: UK
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Telephone: 07400900566
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Date of Birth or age: 25/07/1999
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Please indicate where on the vehicle there is damage using this diagram
Vehicle Damage & Direction of Impact
Churchill insurance policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds, LS1 4AZ. Registered
Page 3 of 12 in
England and Wales No.1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Calls may be recorded.
Claim Number: 201564648
Page 4 of 12
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Please describe the damage to the
vehicle .........................................................................................................................
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Rear bumper had come off, the guy who hit my car didn’t hit it with much speed but was
scrapping across my car for a good 5-8 seconds
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Rim was scratched and so was the side arch
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Driver Losses
Did you suffer any losses as a result of this accident, such as uninsured losses or a loss of earnings?
YES
/
NO
If YES, what losses did you incur? YES I had to pay for a whole nee bumper, a replacement rim and paint work correction
on the side arch, ................................................................................................................................................................................................
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Were you injured as a result of the accident?
YES
/
NO
If YES, please give full details: No not at all, I have just avoid driving at night time if its around a busy time, I don’t trust other drivers.
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Were you wearing your seat belt at the time of the accident?
YES
/
NO --- Yes I was
If NO, why were you not wearing your seatbelt? ....................................................................................................................................................................
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Claim Number: 201564648
Vehicle Details
Churchill insurance policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds, LS1 4AZ. Registered
Page 5 of 12 in
England and Wales No.1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Calls may be recorded.
Claim Number: 201564648
Registration
number
F2far
Make
Volkswagen
Model
Golf
Colour
black
Approximate
speed of travel at
time of impact
15mph
Passenger Details (please complete for each passenger)
Title
Full name
Date of
Birth or
age
Is this person
known to you
(and if so, how)?
Position
in vehicle
Was
passenger
wearing
seatbelt at
the time of
the accident
(and if no,
why not)?
Was
passenger
injured
because of
the accident
(and if so, in
what way)?
Vehicle 2
Vehicle Details
Page 6 of 12
Registration
number
LV56 UAT
Make
Audi
Model
A6
Colour
black
Insurer
Not been told
Approximate
speed of travel at
time of impact
15
Policy Number
Not been told
Please indicate where on the vehicle there is damage using this diagram
Vehicle Damage & Direction of Impact
Damage Description: .........................................................................................
Almost no damage, a few scratches on his front bumper, it was not a bad accident, both of our cars are moving at the same
speed and his is scarping against mine
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Churchill insurance policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds, LS1 4AZ. Registered
Page 7 of 12 in
England and Wales No.1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Calls may be recorded.
Claim Number: 201564648
Page 8 of 12
Driver Details
Title: mr.................................................................................................................................................................................................................................................
First Name: vytautas
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Surname: gaidys
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Address Line 1: 38 holdfield
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Address Line 2: ...................................................................................................................................................................................................................................
Address Line 3: ...................................................................................................................................................................................................................................
City: peterborugh
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County: .................................................................................................................................................................................................................................................
Post Code: pe3 7LW
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Country: ...............................................................................................................................................................................................................................................
Telephone: ...........................................................................................................................................................................................................................................
Date of Birth or age: 12/10/1992
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Description of driver: tall Lithuanian man,
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Churchill insurance policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds, LS1 4AZ. Registered
Page 9 of 12 in
England and Wales No.1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Calls may be recorded.
Claim Number: 201564648
Page 10 of 12
Claim Number: 201564648
Passenger Details (please complete for each passenger)
Title
Full name
Date of
Birth or
age
Is this person
known to you
(and if so, how)?
Position
in Vehicle
Was
passenger
wearing
seatbelt at
the time of
the accident
(and if no,
why not)?
Was
passenger
injured
because of
the accident
(and if so, in
what way)?
Vehicle 3
Vehicle Details
Churchill insurance policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds, LS1 4AZ. Registered
Page 11 of
England and Wales No.1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Calls may be recorded.
12 in
Claim Number: 201564648
Registration
number
Make
Model
Insurer
Colour
Approximate speed
of travel at time of
impact
Policy Number
Please indicate where on the vehicle there is damage using this diagram
Vehicle Damage & Direction of Impact
Front of
Vehicle
Damage Description: .........................................................................................
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Driver Details
Title:
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First Name:
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Surname:
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Address Line 1:
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Address Line 2:
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Address Line 3:
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City:
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Page 12 of 12
Claim Number: 201564648
County:
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Post Code:
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Country:
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Telephone:
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Date of Birth or age:
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Description of driver:
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Passenger Details (please complete for each passenger)
Title
Full name
Date of
Birth or
age
Is this person
known to you
(and if so, how)?
Position
in Vehicle
Was
passenger
wearing
seatbelt at
the time of
the accident
(and if no,
why not)?
Was
passenger
injured
because of
the accident
(and if so, in
what way)?
Churchill insurance policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds, LS1 4AZ. Registered
Page 13 of
England and Wales No.1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Calls may be recorded.
12 in
Claim Number: 201564648
Detail of anyone who saw the accident
Witness 1
Title:
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First Name:
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Surname:
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Address Line 1:
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Address Line 2:
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Address Line 3:
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City:
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County:
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Post Code:
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Page 14 of 12
Claim Number: 201564648
Country:
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Telephone:
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Date of birth or age:
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Is this person known to you?
YES
/
NO
If YES, please indicate how?
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Witness 2
Title:
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First Name:
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Surname:
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Address Line 1:
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Address Line 2:
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Address Line 3:
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City:
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County:
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Post Code:
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Country:
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Churchill insurance policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds, LS1 4AZ. Registered
Page 15 of
England and Wales No.1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Calls may be recorded.
12 in
Claim Number: 201564648
Telephone:
.............................................................................................................................................................................................................................................................
Date of birth or age:
......................................................................................................................................................................................................................................
Is this person known to you?
YES
/
NO
If YES, please indicate how?
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ACCIDENT CIRCUMSTANCES FORM
Policyholder's Name: Mr Adnan Khan Claim Number:
201564648
How did the accident happen?
Its 8;50 the roads were extremely busy as it was in the city centre area and the traffic lights were not functioning like normal as there was road works going on, the road was
merging from 2 lanes into 1, as the traffic light went green me and the other guy accelarted and went around the bend, I had been seeing this road work going on for a few weeks
and I was very well aware that the road is merging into 1 lane once I get around the bend, however on the bend he must have seen that his lane is closing so
he started going from the lef t lane into the right one where I was, this resulted in him hitting the side of my car and scrapping across it and eventually the whole rear bumper was ripped
off at the scene, he would not admit it was his fault, as soon as he had took my contact details he let me take a picture of his driving licence and then headed back on his journey, as his car
was still 100% fine to drive, just a few scratches on the bumper.
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Page 16 of 12
Claim Number: 201564648
Who do you consider is at fault for the accident and why?
I am not taking any resposbility for this accident, it was his fault, the road started to merge and he merged too early into my lane,
he was behind me so there was no way for me to have avoided this accident. Wheresas he could have waited to merge, he could have slow
could have completely stopped and waited for the nest car to give him way to join the single lane.
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What happened immediately after the accident?
We both stopped, I was unable to move for an hour as I had to get my parents to come and collect my bumper, put it in their car and then I drove home, the guy involved in the
accident took my details and headed off 5 mins after. My cousin was also nearby so I called him and he was at the scene around 2 mins after it happened.
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How did you exchange details with the other person/obtain details about the accident if the other person had driven off? W
the other person say at the scene, if anything?
I gave him all my details, I wrote them down for him in my notes and he took a picture, as soon as he was given these he had to go. He said he does not want to discuss
anything about the accident and he will sort it out through his insurer. He was saying it was my fault and I was saying no it is his fault and that was all.
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Do you accept that you were entirely at fault for the accident?
YES
/
NO
Churchill insurance policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds, LS1 4AZ. Registered
Page 17 of
England and Wales No.1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Calls may be recorded.
12 in
Do you accept that you were partly at fault for the accident?
YES
/
NO- no not at all!
If necessary, are you willing to attend court to present your version of the accident? YES
/ NOI don’t believe I need to, it was his fault and the only reason I am not keep complaing about it is because I want to keep
my no claims bonus, if I have to attend then yes I will
Photographs and CCTV or any other evidence you have
None, you can clearly see in the pictures that he drove in the my car, there is abosuly no reason for me to
be moving into the left lane, as the lane is merging into the right.
If you have any photographs, CCTV or any other evidence of the location of the accident, the damage to the vehicles, or
any photographs taken at the scene, please return these with this form, or forward to us in due course.
Page 18 of 12
Claim Number: 201564648
Sketch of Accident
Please provide a sketch of the accident scene which shows:
1
The position of your vehicle at the point of impact
2
The direction you were travelling from and to
3
The position of the other party/parties involved at the point of impact
4
The direction they were travelling from and to
5
The location of any witnesses
6
The road layout
7
Any road markings and road signs
8
Approximate measurements
9
Any other information you think is relevant
Please advise us of anything else of which we should be aware relating to the accident:
Churchill insurance policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds, LS1 4AZ. Registered
Page 19 of 12 in
England and Wales No.1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Calls may be recorded.
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Page 20 of 12
Claim Number: 201564648
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Declaration
I confirm that the details given in these forms are correct to the best of my knowledge.
Before signing below, I confirm I am aware that if I have given any information that is or might be false, or
if I have omitted to answer the questions asked fully, then this may adversely affect the outcome of my
claim. Also, if I dishonestly given any information that I know is or might be false, then I may be
prosecuted.
Signed: adnankhan
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..................................
Full Name: adnan khan
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Dated: 17/08/2022
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Churchill insurance policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds, LS1 4AZ. Registered
Page 21 of 12 in
England and Wales No.1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Calls may be recorded.