Enquiry Form

Have you been hurt in a non-fault accident within the last 3 years ?

If the answer is yes wouldn't you like to find out if you are entitled to compensation ?
Please fill out this simple form and one of our Friendly Accident Co-ordinators will contact you at your earliest convenience in the method most convenient for you.

(If you are under 18, please fill in below the name, address and Contact details for your Parent/Legal Guardian)

Name:

Address:

Post Code:

E Mail:

Daytime Telephone No:
Evening Telephone No:
Work Telephone No:
Fax:


Date of Accident: No Date Selected Accident within last 3 months Accident within last 12 months Accident within last 24 months Accident within last 36 months Accident over 3 years ago

Please indicate the type of accident: No Accident Type Selected Road Traffic Slip / Trip Industrial / at work Other - Enter Below

If type of accident is 'other' - please state what type below:



Best Time to Contact You: (I.E. 1.00 PM)

Preferred method of contact: No Contact Method Selected Any Telephone E-Mail Fax Post