Accident Enquiry

1. Client Details

Full Name

Address

Date of Birth

Contact Numbers

National Insurance Number

Accident Date

Time

Location

Was the accident reported in the Accident Report Book? Yes No

2. Employers Details (For accident at work)

Full Name

Address

Insurance Company

Policy Number

Claim Number

3. Witness Details

Full Name

Address

Telephone Numbers

Full Name

Address

Telephone Number

4. Accident Details

Please provide a detailed version of events

5. Loss Of Earnings

Were you absent from work following the accident?
If 'NO', go to Question (6)

Yes No

Name & address of employer
(or accountant if self-employed)

Occupation

Clocks/Works Number Reference

How long were you off work? From To

Did you lose any earnings as a result of the accident? Yes No

If yes, approximately how much?
( £ )

6. Your Personal Injury Claim

Loss of sleep Yes No

Broken limbs Yes No

If so, which?

Cuts Yes No

If so, where?

Bruising Yes No

If so, where?

Shaken Up Yes No

Trembling Yes No

Anxiety Yes No

Other
(Please give details)

7. Treatment

Please provide your General Practitioner's full name & address

Did you attend your General Practitioner? Yes No

Did you attend Hospital? Yes No

If yes, please provide the name & address of the Hospital

Please state more fully the effects of the accident upon you, whether they have now subsided and how long they lasted

8. Losses

Have you suffered loss or damage to clothing or Personal Effects? Yes No

If yes, please list with details of purchase price, original receipt, age of item and replacement estimate

Please Tick any other claims you wish to make and provide written details below. Please keep any receipts for any out of pocket expenses you incur, as without documentation it is unlikely we will be able to make a claim on your behalf

Clothing Footwear Travel Expenses Private Medical Treatment Other

Please fully describe the ones you ticked

Any other additional information