Download - the Motor Insurers' Bureau

F. PERSONAL INJURY OF SECOND CLAIMANTName of Insured Person: Title (Mr/Mrs/Miss) First Name: Surname:Hospital:Telephone No:Address:Name and address of GP:Town:Postcode:Brief details of injury:Name & Address of Employer:Are you claiming any benefit or losses from any other organisation other than the MIB? Y/NIf yes, please set out the nature of the benefits claimed and the name and address and reference numbers of those against whom you are claiming:Nature of benefit or loss:Reference No:Name and address:Period off work: From: To: National Insurance No:Driver/passenger/Pedestrian/Pedal Cyclist*Reg.No. of vehicle in which traveling:G. DETAILS OF UNINSURED VEHICLE INVOLVEDReg No: Colour: Name of Driver: Title: Mr/Mrs/Miss First Names: Surname:Make & Model:Description of Driver:Address:County:Town:Post Code:Indicate Age of Driver: Telephone No. Home: Business:Under 15/Under 20/21-30/31-40/41-50/51-60/6 1-70/Over 70Name of Owner: Title: Mr/Mrs/MissFirst names:Surname:Area of Impact:Address:Town:County:Telephone No. Home:Postcode:Business:H. ENQUIRIES WITH UNINSURED MOTORISTPlease specify what enquiries you have made to identify the insurers of the uninsured motorist:Letter/phone call to motorist YES/NO — If yes, please enclose a copy of the correspondence or the event of a phone call details of any reply:Enquiry with the DVLA YES/NO - If yes, please enclose DVLA. response.Enquiry with vehicle owner YES/NO – If yes, please enclose a copy of the response.Enquiry with possible insurers YES/NO — If yes, please enclose copies of the correspondence.Name & Address of any Insurers/Brokers mentioned:Town: County: Postcode: Policy/Reference No: