Your Details Name *
Address
Telephone *
Email *
Date of Accident
Dimensions and height of hazard
Condition of pavement
Please describe what happened
Who do you think is to blame, and why?
Name and address of Local Authority responsible for area
Could you provide a sketch plan and photos of the area if required?
Have you reported the accident? If so, what response have you had?
Has the hazard been reported previously? If so, please provide details
How familiar are you with the area?
Has the hazard been repaired? If so, when?
How long had the hazard been present?
Details of any previous accidents in the same area
Full details of injuries received
Did you attend hospital or your GP?
Details of if or when recovered from injuries
Details of ongoing injuries and disabilities
Details of any pre-existing conditions
Details of financial losses directly related to the accident
Any other information you feel is relevant
To help us distinguish between forms submitted by individuals and those automatically generated by spam software, please type the word shown here into the box below.
