HAIL Ref:

Trunk Roads and Motorway Third Party Damage Report

Important TR137/HE1

Please read the notes at the back of this form before completing. If you still feel it is appropriate to make a report, a fully completed form will help process your case as quickly as possible. However, you have to understand that all cases for which we have a correctly and fully completed report form are thoroughly investigated which can sometimes be a lengthy process. We aim to acknowledge receipt within 21 days of receiving them and reach a decision on liability 90 days thereafter. Note  Persons who make fraudulent claims are liable to prosecution.

 If you are under 18 years old, please have your parent / guardian complete and sign this form.

 The provision of this form does not constitute an admission of liability by Highways England or imply that you will receive compensation.  Please use capital letters and tick boxes where appropriate.

 Please complete all relevant sections of this form. You should complete and return this form to the address shown on Page 6. It may be returned to you if incomplete.  If you have any queries in respect of your case, please contact the Claims Branch of Highways England on 0300 123 5000 or by email [email protected].

1 Details of Claimant Title Forename Surname AddressPlease Select eee

Email Address Telephone Number Mobile Landline

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You are required to precisely identify the incident location, date and time before we can formally acknowledge receipt of your claim. Failure to do so may result in our returning the form to you for further information as without this information we are unable to investigate your claim. You may be required to attend a site meeting

2 Particulars of Incident Trunk Road or Motorway (e.g. A1) Direction of Travel A1). Location (e.g. Marker Post, Driver Location Sign Number, OS Grid Reference, Town or other distinguishing features). Date: Time am/pm Description of Incident.

Cause Explain clearly, what you believe to be the cause of the incident, and why you think Highways England has been negligent.

Were you previously aware of the alleged defect in the carriageway?

Did you report your incident at the time? If so when and to whom? (Please include Name and telephone number)

Speed of Vehicle

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Please draw a sketch plan of location

Please indicate as appropriate:-

i. Position of any other vehicles ii. Position of Hazards (e.g. Trips, potholes, debris etc) iii. Place names iv. Any warning signs that were in place

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3 Conditions and Visibility : please give as much information as you can about the following:

Visibility Was the visibility good or poor? Good Poor Were road works present? Yes No

Weather Conditions Dry Wet Windy Fog / Mist Snow Ice

4 Amount Claimed £

Type of Claim (please tick type of claim and fill in the details appropriate to that type) Type A: Damage to Vehicle Details of Damage to Vehicle Photographs of the Damage would help. You are not encouraged to re-visit to take photos on our network

Type of vehicle (e.g. car, van etc.) Registration Number Make and Model Have repairs been carried out? Yes No Copy invoices and / or 2 estimates attached * Yes No Copy of current MOT certificate attached * Yes No Are you VAT registered? Yes No Are you the registered owner of the vehicle? Yes No If No, please explain here why you are claiming

* Do not send originals at this stage as they cannot be returned to you – please retain as we may ask for them at a later date.

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Type A: Damage to Vehicle (Cont’d)

Name of Insurer Address

Policy number

Have you submitted a claim to your motor insurer for the Yes No damage which is the subject of this claim?

Type B: Damage to other property Description of property and/or situation

Details of damage

Is the damaged property available for inspection? Yes No

Type C: Injury to Person * If you have checked this box please fully complete the details in annex 1 on Page 7

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TR137/HA1

5) Witnesses: Were there any witnesses to the incident Yes No

If yes, please supply their details as we may wish to approach them for a statement Name Address

Telephone number

6) If the incident was at the site of road works please give the name of the contractor, if known, carrying out these works.

7) Any other comments that you would like to make?

I declare that these particulars are true to the best of my Knowledge and belief

Claimants Signature Date Data Protection Act 1998 It is intended that the data collected via this form will be used by Highways England for its own purposes and by its formally appointed agents to investigate the incident. Where you provide us with information about another person, you will need to confirm that you have been appointed to act for them, and that they consent to the processing of their personal data. Issues related to the use of personal data within this form should be sent to the address below. 8) Please complete and return to: Red Claims, Highways England, The Cube 199 Wharfside Street, Birmingham, B1 1RN

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Annex 1

Details of Claimant Note: By Law, we are required to notify the Department for Work and Pensions (Compensation Recovery Unit) of the identity of everyone who claims they have suffered personal injury. Details of your date of birth, national insurance number and employer must be given if you have suffered injury for which you are claiming (or intend to claim) compensation.

Date of Birth National Insurance No. Employer Please describe any personal injury that you have sustained

Hospital Details (accident cases only) Was accident a Road Traffic Accident (RTA)? Yes No Was accident relating to a trip or fall? Yes No Did you require the service of an ambulance following the incident? Yes No Did you attend a NHS hospital or G.P. because of your accident? Yes No

If Yes please give details of the hospital(s), G.P. or trust(s) attended or was admitted to in order of attendance

Please be advised we may require medical evidence from your doctor in support of your claim

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Incident causing damage or injury If you have been injured or your property has been damaged when you were using our roads, you may be able to claim reimbursement of your losses. However, there is no automatic right to compensation. The law makes it clear that highway authorities cannot be blamed for everything that happens on their roads. Although Highways England maintains the strategic road network, it cannot be held responsible for every problem which arises: e.g. from the actions of independent contractors and statutory undertakers working on the road, or for the actions of another third party. If you think that Highways England has in some way failed to maintain the highway, then you will have to prove this. You will have to show that the highway in question has not been maintained appropriately with regard to its importance and use and was therefore dangerous. If this can be proved you then have to show that this was the cause of the incident, and that you have suffered a loss as a result. Even if you can prove these things, the law gives a defence to the Highway Authority, and it will not have to compensate you if it can demonstrate that it took all reasonable steps to ensure the highway was safe. This means that all inspections and repairs had been carried out as planned or reported. Unfortunately incidents do occur, however very few are actually attributable to negligence on the part of the Highway Authority.

What happens when I make a claim? Once you have completed this report we will investigate the circumstances in the light of the information you have provided. You may be asked to come to a site meeting with either a member of Highways England or our maintaining agents. You might also need to provide extra evidence to support your claim. When we have finished our investigations, which we would hope to conclude within 90 days of acknowledging receipt of your fully completed form, we will tell you whether we reject or accept your claim. It may be that someone else is responsible for causing the incident or that the place where it happened is the responsibility of others. If this is the case we will let you know and your claim will be against them, not Highways England. How is a claim decided? Our decision will be based on the facts and the law, and will always reflect what we believe to be the attitude of the courts. For example, if we believe the courts would reject a claim, we will do the same. If, on the other hand, we believe that the courts would award compensation, we will offer to settle. Evidence of financial loss or injury You must provide details of your losses and expenditure to support your claim for damage to property. Please send copies of documents and receipted invoices in the first instance but make sure that you keep the originals as we may ask for these at a later stage. If you have been injured, we might pass the papers to the Government Legal Team who may ask for medical evidence from your doctor or other supporting evidence if, for example, you have an additional claim for loss of earnings. By law you must keep your losses to a minimum. For cases involving damage to property, it is advisable to repair the damaged property as quickly as possible as any party paying compensation will only settle the original loss and not any subsequent losses. It is not our normal practice, for example, to pay for a hire car. Professional fees We have well-established procedures for dealing with third party claims. We cannot advise you whether or not to get legal help. If you do ask a solicitor or other professional adviser to act, you might not recover all or any of their fees, even if we accept liability for the incident.

Should I Claim? Please think carefully before making a claim. The road network must be managed and maintained as cost effectively as possible. Highways England is self- insured; therefore, any successful claims are paid from Public Funds.

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