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Customer Accident Management Registration Form

To register your details please complete the form below

General Information
Name:*
Address:
 
Postcode:
Home telephone number:
Mobile telephone number:
Email address:*

 

Car Insurance
Name of insurer:
Policy number:
Renewal date: / / (DD/MM/YYY)
Level of cover: Fully Comp Third party fire & theft
Did you buy direct or through a broker? Direct Broker (Please provide details below)
  Broker Name:
  Broker Address:
Does your policy include optional legal expenses? Yes No Don't know
Does your motor policy include a Guaranteed Replacement Vehicle? Yes No Don't know
Breakdown Insurance/Cover
Do you have any breakdown recovery insurance on your vehicle? Yes No Don't know
If yes please advise provider e.g Manufacturer's, AA, RAC etc.
Renewal Date: / / (DD/MM/YYY)
Vehicle Security Database

To assist you in cases of Battery Failure or if your Keys are lost/stolen, we are able retain your vehicle's security information i.e. your vehicle's key number and radio code.

Radio Code:
Ignition Key Number:
 

Please ensure you do not keep the above numbers in your vehicle

Now please complete the authorisation below to enable us to act on your behalf in relation to any motor claim during your cover period.

By submitting this form you authorise Lexelle Ltd to act as your agents, including discussions with my motor insurer in relation to vehicle accidents/damage.

Occasionally we or our chosen agents may wish to contact you with regard to additional services and offers, if you wish to be contacted in this way, please tick the box

 

Need Advice? Contact Us


Consumer Menu

· Consumer Claim Form
· Accident Management   Registration Form
· Employment Dispute Form
· Motor Accident Report
· Accident At Work Report


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