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Personal Injury Compensation Claim Form

If you think you are entitled to make a personal injury claim please fill out the form below. One of our specialist consultants will phone you back to discuss your situation with you.

You must give us information marked with an asterisk (*) if you want us to phone you. Alternatively you can phone us on 08000 224 224.

Your Details

First Name:
Surname: *
Home Address:
Postcode:
Contact Tel No: *
Email address:
Date of Birth:
Accident/Incident Details
Accident/Incident date?
(DD/MM/YYYY)
Where did it happen?
How did the accident/incident happen?
What was your injury?
Trade Union Membership
Are you or a member of your family in a Trade Union?
If yes, which union?
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Contact us about your accident or injury
Call us for free on 08000 224 224 Call us from your mobile on 0330 123 123 0 (charged at local number and free when covered by inclusive minutes) Request a call back Text CLAIM to 82010 (standard network rates apply)