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Online Assessment for Personal Injury
Please complete the following form:
Step 1.
*
Title
Please Select
Mr
Mrs
Ms
*
First names
*
Surname
*
Home address
*
Post code
*
Home telephone number
*
Mobile telephone number
*
E-mail address
*
Date of birth
Step 2.
*
What was the date of your accident?
*
What time did your accident happen?
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*
Where did your accident happen?
*
How did the accident happen?
*
How could the accident have been prevented?
*
Was your employer at fault for the accident?
Yes
No
*
Did anyone witness the accident?
Yes
No
*
When did you go for medical treatment?
Within 24 hours
Within one week
Within 28 days
Within more than 28 days
Not at all
*
Were you an in-patient at hospital?
Yes
No
*
How long were you in hospital?
nil
1 day
2 days
3 days
4 days
5 days
6 days
1 week
2 weeks
3 weeks
4 weeks
5 weeks
6 weeks
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8 weeks
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41 weeks
42 weeks
43 weeks
44 weeks
45 weeks
46 weeks
47 weeks
48 weeks
49 weeks
50 weeks
51 weeks
52 weeks
More than 52 weeks
*
Please describe your injuries:
*
Have you had any financial losses as a result of the accident?
Yes
No
