1. Tell us about you

Name:

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2. Tell us about your claim

Accident Type: Please select:- Personal injury Medical negligence Professional negligence

Type of Claim: Please select:- Road Traffic Accident At Work Trip/Slip Accident Accident In Shop/Pub/Premises CICA claims Consumer products Other (specify)

Who is negligent? Please select:- GP Hospital Pharmacist Care home Dentist Private physician Other (specify)

Who is negligent? Please select:- Solicitor Architect Accountant Surveyor Financial Advisor Other (specify)

Other (specify):

Date of Accident:

Brief Details: If you miss something out we will contact you for any further details we need to start the investigation.

3. And finally...

How would you prefer to be contacted?

Please Select:- Telephone Appointment Home Appointment Office Appointment Hospital Appointment Email Information Post Information Other (Please Specify)

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Where did you hear about us?

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Which station? Please select:- Viking FM Magic FM KCFM Yorkshire Radio Real Radio Radio Aire