Personal Injury claim form

Personal details

Title:

First name:

Last name:

Address:

Contact phone number:

Membership no.:

8

If you don't have your membership number to hand, please call a member of our team on 0800 709 007.

Email address:

Claim details

Is this claim on behalf of a family member?

Yes No

If answering on behalf of a family member, please provide answers based on their injury / illness.

Date of accident / injury

Please note that there are strict time limits for bringing personal injury claims. To commence court proceedings, generally you have three years from the date of your accident or injury, or the date you knew or ought to have known about your condition or injury. However, there are exceptions and different time limits may apply. Please do not delay in getting in touch with our specialists for advice.

Are you looking to make a claim relating to an asbestos disease?

Yes No

Are you looking to make a claim relating to medical / clinical negligence?

Yes No

Are you looking to make a claim where the person you are claiming on behalf of has died (as a result of the injury / illness the claim relates to)?

Yes No

Are you looking to make a claim where you have / the person you are claiming on behalf of has been hospitalised as an impatient for three days or more (as a result of the injury / illness the claim relates to)?

Yes No

Please provide us with a brief summary of the circumstances of your accident or injury:

Unite Legal Services - personal injury claim form

Personal details

Claim details

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