Make a Claim This process uses automated decision-making to assess whether you have a potential claim. If you would prefer to speak to one of our Legal Support Advisers instead, please click here.Are you making a claim for yourself or someone else?* For Me For someone elseOkay, fill out the form on their behalf – for example, when it asks about "your injuries" enter their injuries, etc.Were you injured in the accident, either physically or psychologically?*Psychological injuries can include post-traumatic stress disorder (PTSD), depression, anxiety disorders or any other mental condition. The effects can sometimes be more devastating/distressing than a physical condition. Yes NoSorry, as you were not injured we cannot help you make a claim.We understand how much, and in all the different ways, an accident can affect your life. For more information about organisations and charities who may be able to help click here.Where did the accident happen?* On the road At work In a public place Medical Negligence My home or Somebody else's Other Did the accident happen in England / Wales?* Yes NoWhen did the accident happen? MM slash DD slash YYYY Date of the accidentI don't remember the exact date I don't remember the exact dateMonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019Because it was more than three years ago, we also need your date of birth: MM slash DD slash YYYY In England and Wales you must start your claim within three years of the accident taking place, unless you were under the age of 18 when it happened.Sorry, it looks like we are unable to help you with this accident as it was more than three years ago.For more information about organisations and charities who may be able to help click here.Have you had any legal advice about this claim?* Yes NoGood news!It looks like you might be able to claim.To get you started we need a few more details about your accident and your injury.First, what can we call you?First Name* First Okay [ClientName], select all the areas where you were injured in the accident Head Area Neck & Torso Lower Body Legs & Feet Arms & Hands All Over PsychologicalWhich part of your head was injured (you can select more than one if needed)?Don't worry if your injured area isn't listed below, simply pick the one most closely related. We'll ask for more specific details later. Brain Cheekbone Chin Ear Eye Face Hair Jaw Mouth Nose Skull TeethWhich part of your upper body was injured (you can select more than one if needed)?Don't worry if your injured area isn't listed below, simply pick the one most closely related. We'll ask for more specific details later. Breast Chest/ribs Collar bone Other internal organ Lung Neck ShoulderWhich part of your lower body was injured (you can select more than one if needed)?Don't worry if your injured area isn't listed below, simply pick the one most closely related. We'll ask for more specific details later. Buttocks Groin Pelvis/hip Stomach TesticleWhich part of your leg(s) was injured (you can select more than one if needed)?Don't worry if your injured area isn't listed below, simply pick the one most closely related. We'll ask for more specific details later. Ankle Foot or toes Heel Knee Leg ToenailWhich part of your arm(s) was injured (you can select more than one if needed)?Don't worry if your injured area isn't listed below, simply pick the one most closely related. We'll ask for more specific details later. Arm Elbow Fingers Hand Nails Thumb WristWhich part of your body was injured (you can select more than one if needed)?Don't worry if your injured area isn't listed below, simply pick the one most closely related. We'll ask for more specific details later. Back Muscles/tendons Skin SpineAreas Injured except PsychologicalNext, please tell us which injury had the biggest impact on your life since the accident. Brain Cheekbone Chin Ear Eye Face Hair Jaw Mouth Nose Skull Teeth Breast Chest/ribs Collar bone Other internal organ Lung Neck Shoulder Buttocks Groin Pelvis/hip Stomach Testicle Ankle Foot or toes Heel Knee Leg Toenail Arm Elbow Fingers Hand Nails Thumb Wrist Back Muscles/tendons Skin SpineIf you have only sustained one injury, please select it below.What was the main type of damage done to your [injury]?AggravatedAllergic ReactionBiteBleedingBrokenBruisingBurnt (not by fire)Burnt by fireCrackedCrushedCutDamagedDisability/ongoingDiseaseDislocatedElectric ShockFracturedGrazedIndustrial DiseaseInfectionJarredLaceratedLostNeedlestick InjuryNoneOtherPainfulParalysisPermanent ParalysisPiercedPoisoningPulledScaldedScarringSlippedSlipped DiscSoft tissue damageSplitSprainedStabbingStrainedSwollenTornTorn Ligaments/TendonsTraumaTwistedWhiplashWhat was the main type of damage that occurred from your psychological injury?AggravatedDamagedDisability/ongoingImpotence/InfertilityOtherStressTraumaIs the injury still affecting your ability to live or work normally? Yes NoPsychological - YesInjury still affecting my ability to live or work normally.Okay [Client Name], let's just check what we've got so far:In an accident at work on 1 January 2017 you suffered a psychological injury. This is still affecting you.We appreciate how important this is to you.We just have a few more questions about treatment and time off work.What medical attention did you seek? GP or practice nurse Walk-in centre Hospital Dentist Optician Other health professional I didn't need any I haven't seen anyone yet, but will soonHow long did you have to stay in hospital?No overnight stay1 night2-3 nights4-6 nights1 week1-2 weeks2-3 weeks3-4 weeks1 month or moreWhen did you visit the GP or practice nurse after the accident? MM slash DD slash YYYY When did you visit the walk in centre after the accident? MM slash DD slash YYYY When did you visit the hospital after the accident? MM slash DD slash YYYY When did you visit the dentist after the accident? MM slash DD slash YYYY When did you visit the optician after the accident? MM slash DD slash YYYY When did you visit the other health professional after the accident? MM slash DD slash YYYY I don't remember the exact date I don't remember the exact dateMonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019Do you think you will require any further treatment? Yes NoHas the accident caused you to take any time off work? Yes NoHow long were you or do you expect to be off work?1 day2-3 days4-6 days7-10 days11-14 days15-21 days22-31 days1-3 months4-6 months7-12 months1-2 years2 years or moreWhat pay did you/do you expect to receive during this time?(Please select the most relevant option) Full pay Part pay Statutory sick pay I wasn't paidWhy didn't you take any time off? I'm not in employment I'm too young to work I'm a full time carer I'm retired Leave / Holiday No Time LostHave your daily activities been affected by the accident?Has your injury reduced your ability to do everyday tasks at home, at work, or out and about? Yes NoOkay Jan, let's check what we've got so far: Summary report here...Incident happened AT ROADYou said it was a road traffic accident, was there an actual collision? Yes NoWhere were you when the accident happened? In a car/van/truck On public transport On a motorcycle On a bicycle I was a pedestrianWhere were you sitting? Driver's seat Passenger seatWhat hit you? Car/van/truck Public transport Motorcycle BicycleWhat type of collision was it?(Don't worry if your exact situation isn't pictured, simply pick the closest one) Rear end shunt From a side road Concertina On a roundabout OtherNow select the vehicle that you were in: Front vehicle Back vehicleNow select the vehicle that you were in: Main road Side roadNow select the vehicle that you were in: Front vehicle Middle vehicle Back vehiclePlease describe the type of collision (including which vehicle you were in):Incident happened AT WORKYou said the incident happened at work, what caused your injury? Attack Ladder Slip/Trip Machinery Lifting OtherYou said the incident happened in a public place. Where did it happen? Pavement or Road Park or Playground Hair and Beauty Shops Health and Fitness Travel Leisure Parking Education Eating out OtherDid it happen on council or privately owned land? Council Private UnsureHow was the accident caused? Slip Trip OtherYou said the incident happened in a public place, where did it happen?Please provide details about where the incident happened...Has the incident been reported? Yes No I'm unsureDid you take any photographic evidence? Yes NoDid you take any photographic evidence = YESWere there any witnesses? Yes No I'm unsureIf you have the witness' details, add them here (don't worry if not).Please provide details of anyone who witnessed the accidentWas there any CCTV? Yes No I'm unsureDid the ambulance service attend the incident? Yes NoDid you tell them exactly what happened? Yes NoIs there anything else you would like to tell us?At the time of the incident, were you self-employed or employed? Self-Employed EmployedIs there anything else you would like to tell us?Who were you attacked by? Colleague Customer Patient OtherWas the attack unprovoked?An unprovoked attack means an assault that you didn’t start or agree to take part in, or which was disproportionate to an initial dispute. Yes NoHas this happened to you before? Yes NoHas anything like this happened before at this company? Yes No I'm unsureHas your employer provided any training that would have prevented the incident? Yes NoFor example your company may provide restraint training. If you are unsure, or your company does not supply this type of training please select 'no'Has this training been issued/refreshed in the last 12 months? Yes NoWould the attack have been prevented if you were provided with additional support from your employer? Yes No I'm unsureAdditional support could include better training, additional staff or equipment.What caused your injury = OtherTell us what happened? (don't worry if not)Thanks [ClientName] for taking the time to share this information with us. One of our advisors will be in touch shortly to check a few things.SurnamePhone numberPostcodeWe need your postcode to help us allocate the right solicitor for youEmail Date of Birth MM slash DD slash YYYY Our advisors are available: Mon-Fri 8am-9pm Saturday 9am-6pm Sunday 9:30am-5pmFind out more about our services here.The information you share with us today will only be used to assess your claim, and is stored securely on our system for up to 3 years. Information on how we handle your data is in the herePrivacy Policy.I have read the above statement* I have read the above statementApprove Icon HereThanks [ClientName], we have your details and will try to call you within 30 minutes, during our working hours.Our advisors are available: Mon-Fri 8am-9pm Saturday 9am-6pm Sunday 9:30am-5pmFind out more about our services here.NameThis field is for validation purposes and should be left unchanged.
