To help us deal with your claim quickly could you please fill in the following details.
Once these have been processed we will contact you.

ABOUT YOU

Name:

Address:

Telephone Number

E-Mail:

Date of Birth:

National Insurance Number:

Employer's Name and Address:

Details of Union Membership if necessary:

THE ACCIDENT

Time & Date:

Location:

In your own words briefly describe what happened:

WITNESSES:

Your Injuries:
when describing an injury to e.g. an arm or leg
please specify if it is your right or left arm/leg etc that has been injured

Have you had time off work?

If "Yes" how long have you had off and what wages do you think you have lost to date?

Other money that you think you or someone caring for you has lost?
Put in what you think may be relevant, if you don't ask we can't help you.

FUNDING:

If you have home or motor insurance or credit cards please tell us
as there may be legal expenses insurance that we can claim on your behalf.