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06th July 2008

Personal Injury Questionnaire

If you have suffered a personal injury (not related to a road traffic accident) where you might be able to claim compensation and would like a no obligation FREE assessment please complete this questionnaire and we will contact you.

Personal Details:

Title (Mr/Mrs/Miss)
Surname
Forename(s)
Address
Post Code
Home telephone
Mobile Telephone
Email Address
Date of birth
Occupation
Employer name
Employer Address
Length of service with employer
Works number
Number of dependants
National Insurance Number

Accident Details

Accident date
Time of accident
Location of accident
Please provide full details of how the accident occurred
Who do you feel was to blame for your accident and why? Please provide their full name and address
Were there any witnesses to the accident? If so, please provide names and addresses
Names and addresses of any persons who can supply any other useful information
Has the accident been reported, and if so, to whom?

Injury Details & Financial Losses

Please provide a brief description of the injuries sustained (if you have suffered an occupation disease, please detail employment history)
Has you fully recovered?
Have you attended hospital as a result of the injuries sustained? If so, please provide name and address
Name & address of your GP
Have you received any other treatment? i.e. physiotherapy. Please provide name & address
Has the accident been registered with the DSS?
Have you suffered loss of earnings as a result of the accident? Please provide dates of absence and estimated loss
Have you received any DSS benefits as a result of the accident? If so, please provide any further details
Please detail any other financial loss or expense that you have incurred as a result of the accident, i.e. travel expenses, prescription charges, etc.