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YOUR DETAILS*
Title: Mr / Mrs / Miss / Ms / Dr delete as applicable

Surname __________________________________ Forename _______________________________

Address ___________________________________________________________________________

__________________________________________Postcode________________________________

Email _____________________________________________________________________________

Contact telephone number ___________________________________________________________

For Personal Injury claims only

Date of birth: _____/_____/_____

National insurance number:

Any other relevant comments that you wish to make

DECLARATION*
In line with Part 6 of the Local Audit and Accountability Act 2014 , the Council participates in the
National Fraud Initiative. The information you provide will be held on computerised systems and/or
papers files, and used for cross-system and cross authority comparison for the prevention and
detection of fraud.

In addition, we will pass your records to our Insurers who will also pass the information to the Claims
& Underwriting Exchange Register; the Motor Insurance Anti-Fraud & Theft register; and other
similar agencies and bodies. We may also share your information with our claims handlers, legal
representatives, contractors or outside bodies who may be involved with the investigation of your
claim.

I declare that the details I have provided in this form are true to the best of my knowledge and
belief. I understand that the information I provide may be shared with other bodies and agencies
as permitted by law and also for the purpose of detecting and preventing fraud. I understand that
action will be taken against me if I provide information that is untrue.

Signature*_______________________________Date*_____/______/______