Submit Personal Injury Claim

Your Name (required):

Mobile Number (required):

Claimant’s Address:

Date of birth:

National insurance number:


Recommended by:

Your Email (required):

Details of injuries:

GP/ Hospital attended?:

Date of attendance:

GP/Hospital Details:

Claimant vehicle registration:

Make, model and colour:

Claimant insurance company name:

Policy number:

Accident date:

Accident time:

Location/Road name:

Brief accident circumstances:

Weather condition:

Claimant’s driver name:

Where were you sitting in the vehicle:

Total number of persons in vehicle (Inc driver):

Vehicle Damage

Claimant Vehicle Damage Description:

Vehicle location:

Is Vehicle driveable?:

Engineer to be instructed?:

Defendant Details



Contact number:

Defendant vehicle registration number:

Make, model and colour:

Defendant insurance company name:

Defendant insurance policy number:

Hire vehicle provided?:

Hire company details:

Contact Number:

Date hire started:

Reported to police?:

Report reference number (Log number):

Name of officer attended:


Any Other Information