Cycle Accident Full Claim Questionnaire

There are three ways to start your cycle claim:

The easiest and quickest way to see if you have a valid claim is to contact us on 0800 387 815 or via email.
Alternatively, complete the simple contact form and we'll contact you at a time that is more convenient.
You can also complete our full claim questionnaire below to start the claim process.

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Full Name(*)

Please let us know your full name

Email(*)

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Telephone(*)

Please provide your phone number

Mobile

Address(*)

Please provide details of your address

(*)

Please select a marital status

National Insurance No

Please enter your national insurance no or write n/a if you don't know yours

Date of birth(*)

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How did you hear of Cycle Aid/Simon A Holt & Co?

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Occupation/Job Title(*)

Please enter your job title or 'n/a' if not applicable

Employer's name & address

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Work Phone Number

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Payroll No (if applicable)

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Date of accident(*)

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Time of accident

Please state time of accident

Location of accident(*)

Please enter location of accident

Please provide a description of how the accident occurred. Describing the position of vehicles, naming all the roads and describe the direction of travel with reference to districts/towns.

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Please describe the weather conditions(*)

Please describe the weather conditions

Please describe the visibility(*)

Please describe the visibility

Please describe the road conditions

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Name and address of other driver involved

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Name and address of other driver's insurers and policy number (if known)

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Registration number, make and model of vehicle involved in accident

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Who do you consider was at fault and why?(*)

Please give your details of the accident

Could either party have avoided the accident?(*)

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Was anything said by the other driver(s) afterwards?(*)

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Was any warning given?

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At the time of accident, were you displaying lights?

YesNo

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At the time of accident, were you wearing any reflective clothing?

YesNo

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At the time of accident, were you wearing a helmet?

YesNo

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Estimated speed at which you were travelling?(*)

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Estimated speed at which the other vehicle was travelling(*)

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Were there any witnesses to the accident?

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Was the matter reported to police?

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Did the police attend the accident?(*)

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Have the police advised you of any intended prosecution?

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Please describe your injuries & current symptoms?(*)

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Were you taken to hospital?

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Were you detained in hospital?

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Name of consultant attending you

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Hospital Reference No (Refer to appointment card)

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What treatment did you receive?

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Were x-rays taken?

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Please describe your injuries and current symptoms

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Have you seen your own GP?

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Have you returned to work?

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If no, will work continue to pay you?

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Are you receiving SSP or incapacity benefit?

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Make and model of your cycle(*)

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Date of purchase

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Purchase price(*)

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Extent of damage to cycle

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Is your cycle on the road?

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Is your cycle insured?

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Are storage charges being incurred?

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Please give details of any damage to or loss of any personal property in the accident

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Travel Fares (give reasons for travel):

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Medical expenses

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Anti-spam

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