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Accident Claims Form

We cannot commence dealing with a claim until we are in receipt of ALL the necessary documentation.
You should not make any attempt at replacement or repair, without prior written authorisation.
If you need help with any part of the form, you can call Direct Group on 0333 003 0600, 9am to 5:00pm, Monday to Friday

ABOUT YOU

Fields marked with an * are required

INCIDENT DETAILS

CIRCUMSTANCES

WITNESSES

THIRD PARTY DETAILS

WAS THE INCIDENT REPORTED TO THE POLICE?*

YESNO

ITEMS CLAIMED FOR

ADDITIONAL INFORMATION

HAVE YOU EVER INSURED YOUR BICYCLES WITH ANOTHER INSURER?*

YESNO

DO YOU HAVE ANY CRIMINAL CONVICTIONS WHICH YOU ARE REQUIRED TO DISCLOSE?*

YESNO

HAVE YOU EVER HAD A POLICY CANCELLED OR VOID BY AN INSURER?*

YESNO

HAVE YOU EVER BEEN REFUSED RENEWAL OR HAD SPECIAL TERMS IMPOSED?*

YESNO

DECLARATION

I declare that the information contained in this form is true to the best of my knowledge and I have not withheld any information connected with this claim. I accept that if I exaggerate any part of this claim, or make any false declaration or statement, I shall not be entitled to receive any benefit under this policy in respect of this claim. Furthermore, I accept that any such action on my part may render me liable to prosecution. I further agree to provide any further information or documentation as may be reasonably required. I understand that you may seek information from other insurers to check answers that I have provided. By returning this form electrically via the Yellow Jersey website in the absence of a signature constitutes acceptance of the declaration.

IMPORTANT NOTICE: Insurers and their agents share information with each other to prevent fraudulent claims and for underwriting purposes via the Claims Underwriting Exchange register operated by Insurance Datatype Services Ltd. A list of participants is available upon request. The information you supply on this form, together with the information you have supplied on your insurance and any other information related to the claim, will be supplied to participants.


Please tick the box to show you have read and agreed to the above declaration

YES

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