Public + Occupiers Liability Accident Form
Your details
Name
First Name
Last Name
Address
House Name / Number
Street
Town/City
County
Postal Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
-
Day
-
Month
Year
Date
Occupation
National Insurance Number
*
Marital Status
Please Select
Married
Single
Co-habiting
Separated
Divorced
Other
Do you have any children?
Please Select
Yes
No
If you have children, what are their ages?
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Defendant Details
The Defendant is the person(s) or company you are making a claim against.
Name of the Company / Firm / Land Owner
Address
Insurance Policy Number (if known)
Insurer Name (if known)
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Details of the accident
Date of the accident
-
Day
-
Month
Year
Date
Approximate time of the accident
Hour Minutes
AM
PM
AM/PM Option
Please provide a satellite / photographs showing the accident location
Photographs of what caused your accident, screenshots of google maps showing the area and photographs of your injuries are all extremely helpful.
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How did the accident happen?
How do you think the accident could have been avoided / what could have been done to prevent it?
Was the accident reported to someone?
Please Select
Yes
No
If so, who was it reported to?
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Injuries + Medical Details
What injuries did you suffer from the accident? Please tick all that apply
Soft tissue
Bone
Whiplash
Other
Did you bang your head?
Yes
No
Not sure
If yes, please give a brief description including whether you lost consciousness and what you banged your head on.
Have you been dizzy at all or fainted?
Please Select
Yes
No
Have you felt any nausea or sickness?
Please Select
Yes
No
Any sensation of 'pins and needles' or pricking sensation in limbs, numbness or loss of sensation?
Please Select
Yes
No
If so, where?
Have you had any trouble with your eyes? (i.,e. double vision or difficulty focussing?)
Please Select
Yes
No
Can you remember all the events leading up to the accident?
Please Select
Yes
No
Some, but not all
Can you remember the accident itself clearly?
Please Select
Yes
No
Can you remember all the events after the accident?
Please Select
Yes
No
Some, but not all
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Neck and/or Back Pain
Please complete this section if you have suffered neck and/or back pain since your accident.
Have you had any neck or back pain?
Please Select
Yes
No
If yes, did it the pain start immediately?
Please Select
Yes
No
If later, how much later?
How long have you had neck and back pain?
Is there any pain on moving or turning your neck?
Please Select
Yes
No
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Broken Bones and Internal Injuries
Please complete this section if you suffered broken bones or internal injuries.
Broken bones: Please describe which bones you had broken, the severity of the injury and any treatment received to date.
Internal injuries: please describe the types of internal injury suffered, the severity or grade of the injury and any treatment received to date.
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Other Injuries
Please complete this section if you suffered shock, psychological trauma, cuts and/or bruising
Did you suffer shock in this accident?
Please Select
Yes
No
If yes, are you fully recovered?
Please Select
Yes
No
If you have recovered, on what date did this happen?
-
Day
-
Month
Year
If you continue to be psychologically affected by the accident, please provide details of your symptoms below (e.g. flashbacks, disturbed sleep, low mood, etc).
Did you suffer with cuts and bruises because of the accident?
Please Select
Yes
No
If yes, please describe in detail where your cuts and bruises are, whether any stitches or sutures were required, how long for and whether they will leave or have left a scar
Please upload any pictures of bruising, cuts and scarring.
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Choose a file
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General Practitioner / Minor Injuries Unit/ Hospital visits for injury treatment
Have you sought medical attention/advice?
Please Select
Yes
No
If yes, on what date did you first do so?
-
Day
-
Month
Year
Did you attend at a hospital as a result of the accident?
Please Select
Yes
No
If yes, please provide the name and location of the Hospital(s) attended:
Were you kept in overnight in hospital?
Please Select
Yes
No
If yes, how many days were you kept in hospital?
Have you seen your own Doctor?
Please Select
Yes
No
Awaiting appointment
If yes, please give the name and address of your Doctor and the dates you were seen:
Do you have any previous injuries or medical issues which may have been affected by the accident? If yes, please give details.
Has a medical expert recommended rehabilitation treatment? (e.g. physiotherapy, talking therapies, etc)
Please Select
Yes
No
If yes, please provide details of the rehabilitation treatment provider:
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Financial Losses and Loss of Earnings
Did you suffer any loss of wages or salary?
Please Select
Yes
No
If yes, how much?
How long were you off work?
You were absent from work from:
-
Day
-
Month
Year
Date
You returned on:
-
Day
-
Month
Year
Date
Your employer's name:
Your employer's address:
Did you receive Statutory Sick Pay?
Please Select
Yes
No
Did you claim SDD Sickness Benefit or Universal Credit?
Please Select
Yes
No
Did you suffer any other financial losses? If so please provide details here
How did you hear about Thatcher + Hallam?
*
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