General Accident Free Assessment Form

If you prefer not to complete the form below then please feel free to ring us on 01536 276300 or 07545235980 for a free no obligation chat.

If you do complete the form then there is no need to answer every question. Just complete those parts that you can and email it to us.

Fields marked with a * must be completed.

Your Details

Name *

Address

Telephone *

Email *

Date of Accident

Please describe what happened

Who do you think is to blame, and why?

Details of any previous accidents or complaints

Full details of injuries received

Did you attend hospital or your GP?

Details of if or when recovered from injuries

Details of any pre-existing conditions

Details of financial losses directly related to the accident

Any other information you feel is relevant

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