Online personal injury and accident form

Please give full answers. Completion of this form does not place us or you under any commitment to proceed - it will simply give us enough information to advise you whether we are willing to take on your case on a no win, no fee basis. If we accept your claim, we will aim to send you full information by post within 2 working days of receipt of your e-mail.

Please rest assured that your details will not be used for any purpose other than responding to your query.

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		Personal Details First Name* Initials Surname* Address* Date of Birth Home Telephone* Work Telephone Mobile Telephone e-mail Address*   Accident Details Date of Accident* Time of Accident Location of accident (please give as much detail as possible, including road names, town etc.) Describe what were you doing there Please set out what happened* (Please describe in as much detail as you can the mechanics of how the accident happened) Please describe any injuries you suffered Were there any witnesses? (If so, please give their names and addresses if you have them) Was the accident reported, if so to whom? (police, your employer, the owner of a shop etc.) Please give any other details you think are relevant

Member of the Law Society's Approved Personal Injury Panel

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