Your Name (required)

Your Email (required)

Your Contact Number (required)

What is your occupation?

Who is your employer?

ABOUT YOUR ACCIDENT

What was the date of your accident?

What time of the day was your accident?

Where did your accident happen?

Is this where you normally work?

Please explain how the accident happened?

Was the accident reported?

Who did you report the accident to and when?

Who do you think is responsible for your accident and why?

Do you have any evidence in support of your accident?If so, what?

Where there any witnesses? Please let us know what they can say about your accident

INJURY

Please provide a brief description of your injury as a result of your accident.

Have you had to take time off work as a result of the accident? Yes.No

Are you still off work as a result of your injury? Yes.No

If you are back to work, how many days in total were you off work?

Did you seek any medical attention as a result of the accident? Yes.No

If yes, what was the date when you first sought medical attention?

Please tick whether you have seen your GP and/or went to hospital? GP.Hospital

If you have been to the hospital, which one?

Did you have to stay overnight? Yes.No

If you did have to stay overnight, how many nights were you detained?

Have you been recommended or provided with any rehab, such as physiotherapy? If yes, what?

FINANCIAL LOSS

Have you lost any income/wages as a result of the accident? Yes.No

If yes, how much and as it this ongoing?

Have you suffered any other financial losses as a result of your accident? Yes.No

What other losses have you incurred?

THANK YOU FOR COMPLETING OUR NO WIN NO FEE QUESTIONNAIRE - WE INTEND TO GIVE YOU A DECISION WITHIN THE HOUR. PLEASE LET US KNOW HOW TO CONTACT YOU.

I consent to Rebecca & Alec contacting me.
I would like to be contacted by email.telephone.