accident at work compensation claims

Accidents at Work Compensation Claim


Personal details

First Name *
Last Name *
Email*
Address:
Telephone:
Preferred method of contact Email/Phone:

Accident date:

How did the accident happen?

Employers name:

Was the accident reported?
	Yes No
Were there any witnesses?
	Yes No
Injury Details

Injury sustained:

Did you attend Hospital?
	Yes No
Did you attend your GP?
	Yes No
Other Information:

Please select from the drop-down list for a free assessment by
a specialist injury solicitor.