Assess my claim questionnaire, please fill in as much information as possible. If English isn't your first language please tell us and we will let you know how we can make your claim easier.
If you are not the injured person please state so here, and your relationship. Yes I am the injured person No I am not the injured person
Answer the questions below for the injured person.
Date of accident or of illness diagnosis?
Date of birth?
What happened?
Whose fault do you think it was?
Why?
Are there any witnesses?
Is there any risk of evidence disappearing eg. ongoing road repairs or building works (if so don't delay)
Nature of the injury?
When did you first seek medical help? And from whom?
How long did you have off work?
How much income did you lose as a result of the accident?
Have you received legal advice already - if so from whom?
How did you find our web site? Google Yahoo MSN Print Advert Referral From a Friend
Name
Address
Email
Phone Number
How would you like us to respond? Email Phone Mobile
When would you like us to respond? ASAP Tomorrow In the Evenings