Accident Compensation Claim Form

If you are one of the 4 million people a year in the UK who suffers an injury in an accident, or you have been the victim of a medical mistake you can now find out for free whether it is worth trying to pursue a claim and just how to go about it by filling out the simple form below. We need at least the information highlighted in blue, but please complete as much of the rest of the form as you can.

If you have been injured in an accident within the last three years let us have the details and we will ask one of our specialist solicitors who cover the whole England, Wales and Scotland, to let you have a free assessment of whether it is worth your while trying to make a claim, what it may be worth, how to go about it and the options for funding any such action. There is no obligation to take the advice given or to use the solicitors who have given the advice. Simply fill in the details below and click submit or call our freephone telephone helpline on 0800 694 0190, or you can ask us to call you back.

If you have any problems or would just like to ask us a question then simply email us.

Accident Claim Assessment Form

The Boring Bit

Your First Name (required)
Your Last Name (required)
Address
Post Code (required)
Email address
Home telephone (required)
Work Telephone (if available)
When is the best time to contact you by telephone?	Morning Afternoon Evening
Is this on your home or work number	Home Work
How would you prefer to be contacted	Telephone Email Letter
Any other instructions about contacting you?
Region in which you live (we will try and find a solicitor within your region if possible)

About the Accident

When did the accident occur?
Where did the accident occur?
Please describe what happened? (required)
Please provide details of your injury (required)
Were there any witnesses to the accident?	Yes No
Do you have their contact details?	Yes No
Have you or your insurers already instructed solicitors to act for you ?	Yes No
Is there any other information which you think may be relevant?

How did you hear about Can I Claim?
(not compulsory, but would be helpful)

If you are happy with the information you have provided click the Submit button and we will have your case assessed and get someone to speak with you. After that it is up to you.

Can I Claim? reserve the right not to answer any queries raised and cannot guarantee in any way that a response will be received within the stated timeframe, nor indeed at all. LAW on the WEB and Can I Claim? accepts no responsibility whatsoever for any advice received from any of our panel solicitors, nor any actions done, or not done, as a result of receiving such advice.

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Accident Claim Assessment Form

Last modified: January 14, 2008