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Personal Injury Specialists

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Employer Liability Claim Form:

1. Your Details: If you are the parent or guardian of a child under 18 years of age, please complete the form in the details of the child for whom you are helping to claim, then in the Additional Information section below, enter your your contact details and your relationship to the child.

First Name Home Contact No. -
Surname Work Contact No. -
Date of Birth - - [dd/mm/yyyy] Mobile Phone No. -
Full Current Address
incl. postcode		 e-Mail Address
2. Accident Details:

Date of Accident - - [dd/mm/yyyy]    
Accident Location Accident Occurred In
Employer's Name    
Employer's Address    


The Accident: Please describe the Accident in as much detail as possible.

 


Your Injuries: Only a brief description of your injury is required at this stage.
Please also mention if you are still suffering any discomfort from your injury.

 
 
3. Evidence Supporting Your Claim: You do not have to answer 'Yes' to all of these questions for your case to be valid. In most instances a case can be founded using only one or two of the items listed below.

Were there any witnesses to your accident that you can contact if necessary?
Was the accident reported to your employers?
Was the accident logged in your employer's accident book?
Was your Health & Safety officer informed of the accident?
Did you receive sick pay from your employer whilst off work?
Did an ambulance attend the scene of the accident?
Did you attend hospital due to injuries you received from the accident?
Did you visit your G.P. due to injuries you received from the accident?
Was anyone else injured in the accident apart from yourself?
Has the item that caused your accident been fixed/removed?
4. Other Information:

Have you submitted this claim to any other legal organisation/solicitor/claims firm?


If Yes: Please give full details of who this was submitted to, when and what the outcome was.
It will not affect your claim if you have been turned down previously by another firm but we do need to contact them before proceeding.


Additional Information: Use this section to give any other information you feel is relevant to your claim.
Please include here your details if you are claiming on behalf of a child under 18 years of age.



Email me a copy of this completed form
N.B.email address field must be filled in

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