| Name | |
| Address |
|
| Telephone Number | |
| Email Address | |
| Do you have any form of Legal Expenses insurance? |
|
|
Have you sought any advice from your Insurers or any other person/organization
about this accident and if so,
from whom and when? |
|
|
Did your Insurers advise you that you could use your own Solicitor to deal with this claim?
Information:
1. If your insurers
have indicated that you cannot use your own
Solicitor,
then unfortunately we are
unable to help you and you should contact your insurers
for
advice on how to
proceed.
2. If however you are
unsure whether you have Legal Expenses Insurance then you will need
to check all
of the insurance documents in
your possession e.g. Buildings, Contents, Car,
Credit Cards
and any others. If there is a
Legal Expenses clause please ask the insurer
if you can
use your own
Solicitor.
|
|
| Are you making this claim on behalf of yourself or another person? |
|
| Name, Address, Date of Birth and relationship to the person on whose behalf you are claiming? |
|
| Date of Birth | |
| Present Occupation | |
|
Employers name, Address and Telephone Number
(We will not contact them without your consent). |
|
| Length of Service | |
| Do you have any dependents, if so how many? | |
| National Insurance Number | |
| Date and Time of Accident | |
| Details of Accident |
|
| Who in your opinion was to blame? |
|
| Please supply the Names and Addresses of any witnesses to the accident |
|
|
Please supply the Names and Addresses of any other person
who can supply information
regarding the accident |
|
| Was the accident reported, and to whom |
|
| Please supply a brief description of your injuries
and the treament that you received for them). |
|
| If the injury was work related please supply details of your work history |
|
| Have you recovered from the injury |
|
| If you attended hospital as a result of the injury please supply the hospital's name and address |
|
|
Your Doctor's name and Surgery Address
(We will not contact them without your consent). |
|
| Please supply details of any Physiotherapy or any other treatments received |
|
| Has the accident been registered with the DSS? | Y
|
| Please provide details of any benefits received from the DSS |
|
| Please detail any other costs you have incurred as a result of the injury, e.g. Prescription Charges or Travel Costs |
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| Image Verification |  | |
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