About This Form

Further to a telephone conversation or meeting with a member of our staff, we note you may wish to proceed with a claim for the recovery of your material losses and/or personal injuries arising out of your recent Road Traffic Accident (RTA) and/or workplace accident. Should you wish to proceed with your claim, we would be very much obliged if you could complete the following questionnaire. Please attempt to be as accurate as you can.

Fields marked with an asterisk (*) are required.

The information we collect

This form has 4 parts. the information we collect in each part is outlined below.

  1. Personal: Your personal information and some incident specific details.
  2. Claim: Information relating to the damages and claim.
  3. Medical: Your Medical information and the injuries you may have sustained as well as your GP/Hospital visit details.
  4. Submit: We will confirm the details and process the submission, this process will be completed by our staff, and we will contact you with 24-48 hours, during normal business hours.

Privacy & GDPR

Please note this is a private form. Please only complete this form if advised by our staff to do so. The data entered in this form is kept in the strictest of confidence and only used to process your claim. All data is handled in accordance with GDPR. Please note this data will be stored for a fixed period of time in order to deal with your claim. You can request this data be deleted or sent to you in accordance with GDPR. Please contact us if you have any questions or concerns.