Online Personal Injury - Accident Claim Form

Online Claim Form

Please complete the claim form below. Your compensation claim will be treated in complete confidence.

Personal Information Title:
Forename:
Surname: Address: Post Code: Telephone: Mobile: Email: Date Of Birth:

Accident/Injury Details Accident Type: Date Of Accident: Where Did It Happen?

Where Did It Happen?

Street name, famous landmark, city e.t.c.

How Did It Happen?

Give a description of how accident happened. Please enter as much detail as possible.

Describe Injuries:

Describe Injuries?

Give a description of all injuries sustained. Please enter as much detail as possible.

Were Police Involved? Yes No
Did You See Your G.P.? Yes No If Yes - G.P. Address:
Did You Go To Hospital? Yes No If Yes - Hospital Address:
Any Witnesses? Yes No

Additional Information Anything Else You Need To Tell Us:

Agreement

I declare that the information / answers provided are true to the best of my knowledge. I irrevocably appoint Claim Now to act on my behalf in respect of uninsured losses (Compensation claim etc.) arising from this accident which was not my fault, and to instruct appropriate Solicitors to deal with this matter.

I have read and understood the information above.

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Submit Claim Click Button To Start Claim:

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Date Of Accident

Where Did It Happen?

How Did It Happen?

Describe Injuries?