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1.
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Forename: |
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Surname: |
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Address: |
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Date of Birth: |
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E-mail address: |
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Home Tel no: |
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Work Tel no: |
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National Insurance no: |
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Name of Employer: |
Self Employed |
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Address of Employer: |
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Works/Clock no: |
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2.
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Please indicate what injuries were suffered
(including bruising, minor cuts or grazes) |
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3.
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Did you attend hospital? If so, please
confirm the full name and address and if possible contact name. |
If yes please provide address
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Were you retained or discharged immediately? |
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were you X-rayed? |
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4.
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Did you attend your G.P.? If yes please
provide name and address. |
If yes please provide address
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| 5. |
Have you had or are you currently undergoing
any treatment as a result of the injury? |
If yes please provide details
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| 6. |
Have you ever sustained any similar injury
other than as a result of this accident? |
If yes please give dates & details
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| 7. |
Has your injury resulted in absence from
work? |
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| a) |
Do you receive full pay during your absence? |
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| b) |
What benefits, if any, do you receive? |
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| c) |
Please advise of dates of absence: |
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| d) |
Please advise whether absence is continuing: |
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| 8. |
As a result of the accident, have you experienced
any of the following? |
| a) |
Nervousness when driving or as a passenger
(where applicable) |
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| b) |
Disturbed sleep and/or nightmares? (where applicable)
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| 9. |
Were you rendered unconscious as a result
of the accident? |
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| 10. |
Has the injury resulted in any expense, for
example:- |
| a) |
Prescription charges? |
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| b) |
Travelling expenses? |
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| c) |
Treatment fees, for example physiotherapy,
osteopathic or hydrotherapy? |
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| d) |
Purchase of, for example, surgical collar,
lumbar support or orthopaedic pillow etc. |
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| 11. |
have you instructed another solicitor
in respect of this accident? |
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| 12. |
Opponents details |
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Full name: |
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Address: |
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Vehicle: (where applicable) |
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Registration no: (where applicable) |
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Insurance details with policy number:
(where applicable) |
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Brief description of accident: |
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| 13. |
Witness details: (where applicable) |
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Witness 1: |
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Full name: |
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Address: |
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Witness 2: |
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Full name: |
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Address: |
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