Online Personal Injury Claim

Submit Your Claim Online

You can complete the form below and submit the information about your claim to us for consideration right now. This will save you time having to send the information to us later and it will allow one of our claim assessors to review your claim and provide you with a quick response confirming if we can act on your behalf or not. Please answer all questions 

Title [Mr/Mrs/Miss/Master/Miss] *	----MrMrsMissMsMasterDrProfessor
Full Name *
Full Address [including postcode] *
Date of Birth *
National Insurance Number *
Occupation *
Telephone number *
Email Address *
Date of Accident *
Your vehicle registration number [only if your claim involves as road traffic accident] *
Time accident occurred *
Defendants Vehicle Registration Number
Defendants Full Name [If known]
Defendants Full Address [If known]
Details of the Injuries you sustained (please supply us with as much details as possible about the injuries you suffered as a result of the accident) *
Did you take any time off work *	----NoYes
If 'Yes' how long were you off from work
Did you visit your GP	----YesNo
If 'Yes' please provide details of your GP and Full Address
Did you visit a Hospital	----YesNo
If 'Yes' please provide Name and Address of Hospital visited
Did you stay overnight in Hospital, if yes please select the number of days	----123456789101112131415161718192021
Was your vehicle damaged [If you were involved in a Road Traffic Accident]	----YesNo
Will you need for us to deal with your vehicle repairs/damage or is your own insurance company dealing with the repairs	----YesNoGoing through own Insurance for damage
If your vehicle is damaged and not drivable do you require a hire replacement vehicle	----YesNo
Were you the driver or passenger of the vehicle [if involved in a Road Traffic Accident] *	----DriverPassenger
Did you have your seatbelt on at the time of the accident [only if road traffic accident] *	----YesNo
Location of the Accident *
Weather Conditions [At the time of the accident if involved in a road traffic accident] *	----DryRainingWetSnowingIceSunnyHeavy Rain
Accident Circumstances [please provide as much detail as possible on how the accident occurred and the what happened after the accident *
Was the police called/notified [if involved in a road traffic accident] *	----YesNo
Please provide details of the police and any reference number provided [if involved in a road traffic accident]
Do you have Legal Expenses Insurance *	----YesNo
How did you hear of our firm	----WebsiteGoogleFacebookRecommendedAdvert (Radio)Advert (TV)Other
If you were recommended by someone please state code if provided with one
I confirm that the above details are supplied by myself as named above to the best of my knowledge *	Yes  No
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Once you click submit to provide details of your claim we will have an expert claim assessor review all the details of your claim to calculate the chances of success in your claim. If the assessor determines that you have a good case that has above 50% chance of succeeding at trial we will send to you a client care pack and a 'Conditional Fee Agreement' which you will need to sign and return to confirm we can act on your behalf on a 'no win no fee basis'.