For your added security this connection to the server is encrypted. Equifax Secure Certificate Authority has identified this site as www.paymyexcess.com.
Please click on the padlock icon in your browser to view full certificate details.

   vehicle excess protection

If you are claiming against your vehicle excess protect policy please take a few moments to complete the form below. On completion please read and accept the Declaration by checking the tickbox. Then click the 'Proceed' button at the bottom of this page and your details will be electronically sent to the Claims Administrator, AXA Assistance.

Policy Number
Vehicle Registration

PLEASE ENTER YOUR REGISTRATION NUMBER WITH NO SPACES
Excess policy limit purchased
£500

Contact Details

Title
Forename
Surname
Address
Post Code
Email Address
Contact Telephone No.
(This will only be used if we have problems contacting you, for example - emails being blocked/down)
Age of Policy Holder

Your Vehicle Excess Protect Policy Details

Have you previously made a claim under this Vehicle Excess Protect Policy?
  
On receipt of this claim form by AXA Assistance they will verify your certificate information. If you have previously claimed during this policy period they will calculate what indemnity excess still remains in force. Only the remaining balance will be claimable.

Claim Details

Incident Date
Click on icon to access calendar
Please state the amount of excess that you are claiming £
(this figure must match the excess you are responsible for on your settlement letter from your Insurance Company)
Country of Incident

Are you claiming as the Policy Holder?
  
If no please complete the additional claimant details below.
Title
Forename
Surname
Address
Post Code
Email Address
Age of Claimant if not Policy Holder
Please Name Your Main Insurance Provider
Main Insurer's Telephone No.
Claim Number / Reference Number
(For internal purposes only)
Vehicle Type
Vehicle Make
Vehicle Model
Year of Manufacture
Type of Incident
Time of Incident
Type of Insurance
Vehicle Usage
Did your accident happen whilst on business?
  
Are you a Qualified Driving Instructor?
  
If Yes, did the accident occur whilst teaching?
  

IMPORTANT INFORMATION FOLLOWS

There are two usual methods of your claim being paid - please select your preferred method of payment. However, if you require an alternative method of payment please select 'alternative'.

Bank Details

Please note that any settlement made by us would be via a bank transfer directly to the appropriate bank account. Accordingly please provide the following information:
Full Name and Address of Bank
Account Name
Account Number
Sort Code
Routing / Swift Code
(if applicable)

Cheque

A cheque will be made payable to the named insured and sent to the address as detailed in this claim form.


AXA Assistance will contact you shortly to obtain the details.

Declaration

Please Note; By ticking this box you are providing us with your authority to communicate with your main policy insurer to further validate the claim where necessary and obtain the details of any third parties who we may approach, if applicable, for the subrogation of your claim under this vehicle excess protect policy. The information supplied to us by you may be held on computer and passed to other insurers for underwriting and claims purposes. When you tell us about an incident we will pass information relating to it to a database. We may search these databases when you have a claim to validate your claims history or that of any other person or property likely to be involved in the policy or claim. In order to prevent and detect fraud we may at any time: Share information about you with other organisations and public bodies including the Police; Check and/or file your details with fraud prevention agencies and databases, and if you give us false or inaccurate information and we suspect fraud, we will record this.

If you do not wish to proceed with submitting your claim online or require an explanation for regarding some aspect of this statement please call 0845 271 2467.

NEXT STEPS

  1. Please check that all the details that you have supplied are correct
  2. When the details have been received by us (AXA Assistance) we will respond by emailing a letter confirming receipt of your details which will include a claim reference number, which you must use in all future correspondence with us.
  3. You now must send to us, upon receipt of the letter from AXA Assistance confirming they are dealing with your claim, the following documentation:
    1. A copy of your Vehicle Excess Protect Certificate of Insurance.
    2. A copy of your settlement letter from your Insurance Company, which must state the amount settled and the excess deducted.
Please return the requested documents to:

AXA Assistance Limited
PO Box 54098
London SW20 8UU

Tel: 0845 271 2467
Email: lifestyle-excess@axa-assistance.co.uk

Please allow 10 working days upon receipt of your claim to AXA Assistance for them to process your claim. We recommend that you take full copies of this form and documentation enclosed.