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Claim form - personal injury and damage to property


									Guidance on claiming compensation relating to incidents on the highway
causing personal injury

If you have been injured as a result of an incident on the highway, you have the
right to make a claim for compensation.

The Civil Procedure Rules (CPR) were introduced in April 1999, to deal which
such claims for compensation. The Rules require both parties to establish all
the relevant facts to the claim in order that it can be dealt with expeditiously
and fairly in an attempt to avoid litigation.

The County Council’s Claim form for accidents on the highway is designed to
assist you in providing all the relevant information and documents we require
to deal with your claim. Please ensure it is completed properly.

Every claim is determined on its own merits applying legal principles and it is
the Council’s policy to defend all claims where it considers that it has not been
negligent or in breach of its statutory duty to maintain the highway.

Our claim form contains a declaration that you are verifying that the
information and documents you submit in support of your claim are true to the
best of your knowledge and belief and are not misleading. You should be
aware that the consequences of deliberately signing an inaccurate declaration
could potentially be very serious.

Please note that there is no automatic right to compensation. The law makes it
clear that the County Council cannot be blamed for everything that happens on
the highway and also recognises that although defects may be present, the
County Council cannot be held responsible if it was unaware of the presence of
such defects. In addition, the County Council cannot be held responsible for
every problem arising out of the actions of third parties, independent
contractors and statutory undertakers.

The Highway Authority must acknowledge your completed claim form within
21 days and it then has a 3 month period to investigate the claim and report on
whether compensation is to be paid to you, so we would be grateful for your
patience whilst we process your claim.

Your name and address will be recorded in our database and we are obliged to
inform you that information provided to us may be passed to others for the
purpose of detection and prevention of fraud. This includes, but is not limited
to, the Claims and Underwriting Exchange (CEU) run by the Insurance
Database Services Ltd (IDSL), the Motor Insurers Anti-Fraud Register run by
the Association of British Insurers (ABI).
                                                                                   Page 1 of 4

Ref :

                         HIGHWAY PERSONAL INJURY CLAIM


Data Protection Act 1998
Your personal data will only be used to process your claim and for no other purpose.
Processing includes holding data electronically. Where a personal injury is involved we are
legally obliged to register your claim with the compensation recovery unit but your data will
not be passed to any other organisation unless we are required to do so by law.

1   Claimant’s full name :   ____________________________ _______________ ____

2   Claimant’s full address : _____ ______________________________________ _ __

    ________________________________________________ ______________ _ __

    _________________________________________ Post Code ____ ______                          _

    Contact telephone number: ______________________________________________

    Email address: ________________________________________________________
    (Note: If you provide an email address we will correspond with you via email unless you
    advise us otherwise)

3   Claimant’s Date of Birth : __________________________ _____                             __

4   Please provide details of the location of the defect or problem to enable us to locate it :

    _____________________________________                                                  ___

                                        ___________________________________ _____

                                                                                    Page 2 of 4

5   Please illustrate the location of the defect and direction of travel below :

    If you have any photographs please enclose a copy to help our investigation.

6   Date of Accident : _________________ ____ _______________________________

7   Time of Accident : _____________________ _______________________________

8   Weather conditions : ____ _______________ _______________________________

9   Please describe as precisely as you can the defect or problem with the Highway :

    ___________________________________________________                     _______________

    ________________________________________________                    __________________

    _____________________________________________                    _____________ ______

    _______________________________________________                   ___________________

    _______________________________________________                   ___________________

10 Please provide a brief description of the circumstances of the accident :

    ______________________________________________________________                        ____

    _______________________________________________________                        ___________

    ______________________________________________________________                        ____

   ______________________________________________________________ ____
11 Please give details of any claim for damage or costs incurred and include copies of receipts :

    ___________________________________ ____                        _________              ___

    __________________________________               ________________________________
                                                                            Page 3 of 4

12 Additional Information.

    (a)     Information required for compensation recovery unit.

               Claimant’s National Insurance Number : ___________________________

               Name and address of any Hospital attended : ________________________



    (b)     Description of personal injury sustained
            (include details of any treatment received) : ___________________________

            _              ______________________                                  ____

            _          _________________        _____                              ____

    The above information and details are true to the best of my knowledge and belief.

    Signed: ________________________________             __

    Print Name : __________________________________

    Date: __________ __________________             ______

Where to send your completed form

Details of where to send your completed form are on page 4 of this form – please turn
                                                                                Page 4 of 4

Where to send your completed form

Claims are dealt with by the highway office that is closest to where the incident
Please post this completed form, with any photographs and copies of receipts, to any of
these office addresses, but preferably to the one closest to where the incident took place.

For Fareham and Gosport areas                 Highways Manager
Highways Manager                              Highways Area East
Highways Area South                           The Old College
Civic Offices                                 College Street
Civic Way                                     Petersfield
Fareham                                       GU31 4AG
PO16 7AZ

Highways Manager                              Highways Manager
Highways Havant                               Highways Area West
Civic Offices                                 Jacobs Gutter Lane
Civic Centre Road                             Hounsdown
Havant                                        Totton
Hampshire                                     Southampton
PO9 2AY                                       SO40 9TQ

Highways Manager                              For Winchester area
Highways Area North                           Highways Manager
M3 Motorway Compound                          Bishops Waltham Depot
Hook                                          Botley Road
RG27 9AA                                      Bishops Waltham
                                              SO32 1DR

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