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Find out if you might have a claim and how much your claim could be worth by answering a few questions and a dedicated claim handler will be in touch to finalise your claim and see if you want to take it forward.

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First Name

Last Name

Date of birth

Phone number

Postcode

Name of Injury

Please Provide the details of your injuries

How many weeks have you been off work or expect to be off work with this injury?

How much salary have you lost or expect to lose as a result of your injury?

How much in terms of company benefits have you forfeited due to your injuries?

If someone has had to stop working to take care of you, how many weeks have they taken off or expect to take off?

How much of their salary have they forfeited or expected to forfeit as a result?

How much have you spent on travel expenses as a result of your injuries?

How much have you spent on prescriptions as a result of your injuries?

How much have you spent on personal care or assistance as a result of your injuries?

How much have you spent on hire car/car repairs/insurance excess as a result of your accident?

What was the date of your accident?

What type of accident was it?

Please describe the accident in as much detail as possible

Were there any witnesses? If so please include their details here

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