Bike Claims Form

Policy & Loss Information

Policy Number *

Date of Loss *

Time of Loss

Policy Holder Information

Policy Holder Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Email Address

Operator Information

Name of Operator

Date of Birth

Bike Information

Year

Make

Serial #

Accident Location

Describe the Accident

Describe Damage to the Unit

Describe any injuries and to whom (list any third parties)

Other party involved: Owner

Other party involved: Driver

Address of owner

Plate #

Insurers

Policy #

Type of unit & details

Police notified at

Occurrence #

Charges laidYesNo

Against

Insured

Third Party

Give names and address of witnesses

This claim is forPhysical damage to unitLiabilityAccident benefits for operator

Acceptance

I understand that inflated or fraudulent claims is an offense and will be prosecuted. The foregoing statements are true and correct to the best of my knowledge, and are submitted as a claim under the said policy.

Date

Additional

I would like The Biking Lawyer team to contact me about this crashYesNo

Upload file(s)

Your safety and privacy is our utmost concern. Claim and personal information is securely stored with Bicycle Broker Inc. Shared only with our Claims Adjusters at Lloyd's of London and optional Legal Helpline facilitators. If you decide to retain services from the Biking Lawyer LLP this information will be moved to their secure legal database. No matter what your information will not be used for any purpose that you do not directly advise us for. It will not be shared, copied, or sold to any party without your express written permission. Data will be stored for 2 years to protect your legal rights and then permanently deleted.

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