Online Claim Form

If you have been injured in an accident in the last 3 years**, or if you have discovered in the last 3 years that you are suffering from an illness, and that the injury or illness may be someone else's fault, you may be entitled to submit a claim for compensation.

If you would like us to consider your case and you would like to contact us online, please fill in the details below. We will contact you as soon as we receive your details. Fields marked with a * must be completed.

** for children, claims must be submitted within 3 years of reaching the age of 18.

Your Details

Title: Please Select... Mr Mrs Ms Miss
 
First Name: * Last Name: * Address: Preferred Contact Number: * Alternative Contact Number: * Email: * Preferred Contact Time: Please Select... ASAP Morning Lunchtime Early Evening Anytime

Accident Details

Date of Accident: Month Jan Feb March April May June July Aug Sept Oct Nov Dec Day 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st Year2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1987 1986 1985 1984 1983 1982 1981 1980
 
Type of Accident: Please Select... Road Accident Accident at Work Slip, Trip or Fall Other
 
Accident Details:  
 
Mandatory: To help us distinguish between forms submitted by individuals and those automatically generated by spam software, please type the word shown here into the box below.