Personal Injury Claim - Not My Fault

Please take the time to complete this questionnaire as accurately as possible. To effectively advise you, we will need as much relevant information as you can provide from the very start. This questionnaire will form the basis of our initial case assessment. If we do not have full details of your case now, it may not be possible to make a claim for all of your losses at a later stage.

Personal Details

Legal Insurance

do you have legal expenses insurance under your house insurance to fund your legal costs in bringing a claim? yes

do you have legal expenses insurance under your car insurance to fund your legal costs in bringing a claim? yes

do you have legal expenses cover to fund your legal expenses from any other third party? For example, a union or credit card? yes

Your Personal Injury Claim

Did the accident happen within the last 3 years?

If no, please explain briefly why you think it was somebody else's fault

If it was partly your fault, please explain:

Please provide a brief description of injuries

Helpful Evidence

Please think about how we might prove the key elements of your case. This evidence may be in the form of documents or witnesses. Please provide details below.

If you know of any witnesses, please provide their full name, date of birth, phone number, address and a note of what they might say.

Witness 1:

Witness 2:

Please provide your GP's details below.

Upload pre-prepared statement

If you prefer, you may send us a pre-prepared a statement, in Microsoft Word, WordPad or Notepad format. (Maximum file size of 512Kb)

How did you find us?

To assist us with our Market Research, could you please indicate how you found this site? If you used a search engine, could you let us know which one, and what keyword(s) you used?