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submit an rta claim

Telephone Mediation Batch Submission Form

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submit an rta claim

last modified 03 October 2007 09:49

If you have recently been instructed and wish to complete an online 2.6 notice please fill out the form below. Once the form is completed you will have the opportunity to print the details you have submitted, which you can then forward onto the respondent as a formal notice.

Claimant's Details

Claimant's Name (Required)

Claimant's Date of Birth (Required)

National Insurance Number (Required)

Lawyer's Details

Name of Lawyer (Required)

Law Firm (Required)

Firm's Building Name/Number (Required)

Address (Required)

Address

Post Code (Required)

Telephone Number (Required)

Lawyer's Case Reference (Required)

Basic Details of Intended Claim

Name of Respondent (Required)

Name of insurer per M.I.D (Required)

Vehicle Registration Number (Required)

Vehicle Make (Required)

Vehicle Model (Required)

Policy Number (Required)

Date of Incident (Required)

DD/MM/YY

Place of Incident (Required)

Brief Circumstances Of Incident* (Required)

*This is a descriptive summary only and does not represent a full description of the nature of the injuries or losses suffered. This is subject to further review and does not limit the claimant's rights in any way.

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Brief Nature of Injuries and Prognosis (Required)

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Any Special Damages?

Special Damages? (Required)

Yes
No

If yes, please give details of loss of earnings and/or any other major heads of loss. (schedule to be completed at a later date)

Any other relevant factors?

Your email address (Required)

IMPORTANT - You must enter a valid email address so that a copy of the contents of this form can be emailed to you. You can then print this email.