Complex Investigations New Matter Client Name Underwriter Company Name File_Handler First Name File_Handler Last Name File_Handler Contact Number File Handler Email Your Reference Policy Reference Date of Instruction Urgent? (Please select) Yes No If so, reason, litigated, credit hire, portal deadline, etc. Policyholder Title Mr. Mrs. Ms. Mx. Dr. Miss Hon. Rev. Rabbi Rep. Sen. Master Sir Lady Policy_Holder First Name Policy_Holder Last Name Policy_Holder Date of Birth Policy_Holder Email Address Policy_Holder Phone Number 1 Policy_Holder Physical Address Line 1 Policy_Holder Physical Address Line 2 Policy_Holder Physical Address City Policy_Holder Physical Post Code Policy_Holder Occupation Policy_Holder Vehicle Registration Number Policy_Holder Vehicle Make and Model Reasonable adjustments? Interpreter required? (Please select) Yes No Spoken language Third_Party First Name Third_Party Last Name Third_Party Physical Address Line 1 Third_Party Physical Address Line 2 Third_Party Physical Address City Third_Party Physical Post Code Third_Party Phone Number 1 Third_Party Vehicle Registration Third_Party Vehicle Make and Model If multiple claimants provide details Please state Full name, Address, Postcode and Phone Number Fraud type (Please select) Pre-inception loss Staged/contrived Induced Theft Fire/flood Fraud ring Credit hire Exaggerated losses Policy - spoofing Policy - driver not insured Policy - drive not identified (MIB) Policy - ghost brokering/fronting Policy - motor trade Policy - misrepresentation Malicious damage/vandalism Other If you have no fraud concerns and the instruction concerns liability only, please complete the document version of the instruction form and send it to motor.admin@questgates.co.uk. If other please specify? Date of Incident Time of Incident Location of incident Policyholder's version of events Reason for referral Please include the details of any witnesses or companies of concerns etc. Policyholder reserve Third_Party Reserve Total Reserve if unsure please provide an estimate total reserve Notes about the reserve Number of keys Keys with insured (Please select) Yes No Keys with insurer (Please select) Yes No Current location of the vehicle Has the vehicle been deemed a total loss? (Please select) Yes No V5C supplied and attached via email? (Please select) Yes No Engineer's report supplied and attached via email? (Please select) Yes No Purchase receipt supplied and attached via email? (Please select) Yes No
