30-Second Claim Form

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30-Second Claim Form

For a FREE initial assessment of your case, please complete the form below IF and ONLY IF, you satisfy the following criteria;

a) you have been injured in an accident in the past TWO years

b) The accident was NOT your fault

c) You received medical treatment as a result of your injuries

d) You have not previously made a claim for compensation for this accident.

30-Second Claim Form

Please note that all fields followed by an asterisk must be filled in.

Title

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Preferred Contact Number*
Preferred Contact Number*

Best time to call you?*
Best time to call you?*

Date of Accident*
Date of Accident*

Type of Accident or Incident*
Type of Accident or Incident*

Was accident your fault?*
Was accident your fault?*

	No
	Yes

Were you injured?*
Were you injured?*

	Yes
	No

Were your injuries treated by your GP/hospital?*
Were your injuries treated by your GP/hospital?*

	Yes
	No

Have you made a previous claim for this accident?*
Have you made a previous claim for this accident?*

	No
	Yes

How did you hear about us?*
How did you hear about us?*

If 'Referral' or 'Other' please give details

Please enter the word that you see below.

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