Your details
Full Name
Address
Postcode
Email address
Phone Numbers
Home
Work
Mobile
Date of Accident
Time of Accident
Location of Accident
Name and Address of Employers
Please describe what happened
Who do you think is to blame, and why?
Names and addresses of any witnesses
Was the accident entered into the Accident book? If so, give details
Job title and description of work
Length of time and experience in job
Details of any pre-accident instructions, warnings, precautions or notices issued or received
Details of any pre-accident training received
Details of any pre-accident complaints received
Details of any protective clothing or equipment used
Details of any changes introduced as a result of the accident
Details of any previous or similar accidents
Full details of injuries received
Did you attend hospital or your GP?
Details of treatment received
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?
