Cycle Insurance Claim Form We like to settle claims quickly and justly. Claims can be settled in a few days or take a number of months. Most delays are caused by claimants not completing this form or not including the necessary documentation. Step 1 of 7 14% About youETA number*Name* First Last AddressAddress First Line*Second Line (Optional)City or Town*County*Postcode*Contact DetailsEmail* Enter Email Confirm Email Phone* About Your Claim - in shortType of Incident*LossStolen partsAccidental damageRoad traffic incidentDate you left the cycle*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year201820172016201520142013Time you left the cycle* : HH MM Date you returned to the cycle*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year201820172016201520142013Time you returned to the cycle* : HH MM Location of Incident*Please include a postcode where possible. About Your Claim - in detailState circumstance in which loss/damage occurred and exact details (include if loss was by theft, how entry was obtained – which doors/windows were forced, please also state the make and model of lock if used to secure your bike) About Your Claim - policeWas Crime Reported To The Police*YesNoReported to which Police station*Police crime reference number*Police station telephone numberErrorThe type of claim you are making requires the incident to be reported to the police. Claimed ItemsClaimed item details*Make & modelEstimated value or repairs or replacements You can add extra rows by clicking the green 'Add' iconRelated Insurance and Third PartyDo you have home insurance?YesNoFailing to disclose this information at this stage may delay or prejudice your claim.Is the bike covered by any other policies, for example household insurance or manufactuer's warranty?YesNoFailure to provide this information, may delay your claimPlease state the name and address of the insurers, the relevant policy number, and include a copy of the policy statement (this can be uploaded at the end of the form)Failure to provide this information, may delay your claimInjury or BlameWere you injured?NoYesDo you feel someone else is to blame for the incident?NoYesPersonal Injury HelplinePlease call our personal injury helpline, the number is 0845 389 1050 Bank DetailsName of Bank/Building Society*Account Holder Name*Account Number*Sort Code* CompletionFile Upload Drop files here or Please upload any files containing evidence relevant to your claim such as photos, receipts and other files.Confirmation* I have provided Proof of Purchase I have provided VAT registered trader's estimate for cost repair/replacement I have provided other evidence I believe relevant to my claim DeclarationDeclaration* I confirm that the information entered on this form is true and accurate to the best of my knowledge This iframe contains the logic required to handle AJAX powered Gravity Forms.