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Have you had an injury as a result of an accident?
Required Required Question(s)
The following questions are designed to help us find out whether you have a potential claim for damages arising from an injury or illness.

Completion of the questions is entirely without any obligation.

After completing the questionnaire we may contact you to advise you whether we think you may have a potential claim and to discuss your claim further with you.

Your details will not be passed on to any third party.
 
Required 1.
Have you suffered an injury or become aware of an injury, disease or illness during the last three years?
Yes
No
Required 2.
Was the incident causing your injury:
A road traffic incident
An incident at work
A tripping or slipping incident
A crime or attack by another person
A clinical error or a mistake by a doctor or other medical professional
Related to an industrial disease
Other 
3.
Please provide brief details of what happened to cause your injury
 

  • 500 character(s) left.
4.
Was anybody else injured as a result of the same incident?
Yes
No
Required 5.
Have you attended a doctor or visited a hospital, clinic or other medical professional about your injury?
Yes
No
6.
Please describe the injuries that you have suffered.
 

  • 500 character(s) left.
Required 7.
Have you already complained to anyone about the incident causing your injury? If so, please confirm in the comment box who you complained to.
Yes
No
  • Comment:

  • 150 character(s) left.
Required 8.
Have you approached a solicitor before now to pursue a claim on your behalf?
Yes
No
Required 9.
Please confirm your full name
 

  • 50 character(s) left.
Required 10.
Please provide your email address
 

  • 50 character(s) left.
Required 11.
Please re-type your email address to confirm.
 

  • 50 character(s) left.
12.
Please provide a contact telephone number:
 

  • 50 character(s) left.
13.
Please confirm the best time of day for us to contact you by telephone to discuss your claim:
7am to 9am
9am to 1pm
1pm to 5pm
5pm to 9pm