Forms

Initial Claims Questionnaire

If you would like us to make an initial review of your claim, please fill in the form below and click on "Submit".

If you have already filled a form and would like to make some changes to it, please enter the Form Number of the original form you filled in and your email address, then click "Retrieve".

Retrieve Previous Form Form Number Email Address

Initial Claims Questionnaire (items marked with * are required) Your Details Form Number *New Form* Title *First Name *Surname *Gender MaleFemale Address 1*Home Phone 1*Work Phone 1*Mobile 1At least one phone number must be supplied *Email Date of Birth (dd/mm/yyyy) The Accident *Date of Accident (dd/mm/yyyy) *Accident Location *Accident Description *Have you been off work due to the accident? YesNo Injury Details *What injuries have you suffered? *What is your present condition? *Did you attend A & E? YesNo *Have you had any treatment (e.g. Physio)? YesNo What prognosis did your GP give you? Did you suffer from any of these symptoms before the accident? YesNo If yes, please explain Previous History Have you been involved in any previous accidents or litigation? YesNo If yes, please explain Police Were the Police informed? YesNo If yes, Police reference Details of attending officer or address of Police station

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