Data Breach Enquiry.

1

The information given to us in this questionnaire will enable us to accurately assess your claim.

It is important that the information that you give is accurate to the best of your knowledge and where possible please ensure that you have up to date contact details for the company involved in the breach.

Please either upload or store safely any documents that you refer to in this questionnaire as we may need these from you at a later date.

2

Name

Title

First Name

Last Name

3

Email

example@example.com

4

Phone Number

Area Code

Phone Number

5

Brief description of the Data BreachYou may be asked further information to assess your claim.

6

Can you provide us with more detail about the Data Breach?The more information you can provide, the quicker and more accurately we can assess your claim.

YESNO

7

Date of IncidentIf you are unsure please give as close as possible

Date

8

What date did you discover the breach?If this is different from above

Date

9

Data Breach Company detailsPlease enter as much contact information as you have about the company responsible for the breach. This information helps

10

Have you reported the incident to either the Company, the ICO or the Police?

Company

ICO

Police

Other

11

Do you have a company account number or reference

Yes

No

Unsure

12

Date of BirthBreach Victim

Date

13

Nationality

14

Are you happy to receive documents via email?No = Documents being sent via post

YESNO

15

Are you currently a UK resident * This field is required.

YESNO

16

Please give any further relevant details about the BreachAny other relevant information

17

Please upload any evidence that you have.ie. Correspondence, emails etc - This information will be kept secure.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

18

19

20

Your information will be reviewed by a Solicitor and in some cases a Barrister. By submitting your details you are agreeing to this.