0161 624 3210
Home
What to claim for?
What we can do?
Types Of Claims
Road traffic injuries
Car Accident Injuries
Cycle Accident Claims
Bus Accident Claims
Taxi Crash Incidents
Work Related injury claims
Construction Accident
Fall from Height
Forklift Accident Claim
Repetitive Strain Injury
Travel Claims
Accident at the Hotel
Cancelled Flight (X)
Flight Delay (X)
Holiday Food Poisoning (X)
Slip Trip at Hotel (X)
Personal injury claims
Criminal Injury
Dental Negligence (X)
Dog Bite
Medical Injury (X)
Slip and Fall (X)
Sports Injury
Uninsured Accident
Get in Touch
RTA
ROAD TRAFFIC ACCIDENT
1
Personal Details
2
Accident Details
3
Parties
4
Injuries
5
Credit
Section 1- Client Details
Date
*
Name
*
First
Last
Address
*
Street Address
City
Postcode
Personal Details
Landline Number
*
Mobile Number
Email
*
Date of Birth
National Insurance No
Occupation
Accident Details
Claiming For
*
Personal Injury
Vehicle Damage
Loss of Earnings
Instructed another solicitor?
Yes
No
Date of Accident
*
Time of Accident
*
Location of Accident
*
No of Occupants (inc driver)
*
Were the police involved?
*
Yes
No
Police No/Station: Accident Circumstances
Are you the:
*
Owner
Driver
Passenger
Accident Circumstances
*
Weather Conditions
*
Sunny
Ice
Rain
Fog
Snow
Dark
Road Conditions
*
Dry
Ice
Wet
Snow
Who is to blame?
*
I am at fault
Third party driver
Parties
Client Driver Name
*
Vehicle Registration
*
Make / Model
*
Colour
*
Insurer / Policy No
*
Third Party Driver Name
*
Were you wearing a seatbet?
*
Yes
No
Injuries
Please specify your injuries
*
Whiplash
Soft Tissue
Bone
Other
If Other, specify below:
Other Injury
Areas Affected
*
Neck
Back
Shoulder(s)
Have you fully recovered from your symptoms?
*
Yes
No
Did you visit the hospital?
*
Yes
No
Hospital details
Name of Hospital
*
Date visited hospital
*
GP Details
Did you visit the GP?
*
Yes
No
Date visited GP?
*
Comments
Passenger Details
How many passengers were in the vehicle?
*
One passenger
Two passengers
Three passengers
Four passengers
Passenger 1
Name
*
First
Last
Telephone Number
Work Number
NI Number
Occupation
Date of Birth
*
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Passenger 2
Name
*
First
Last
Telephone Number
Work Number
NI Number
Occupation
Date of Birth
*
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Passenger 3
Name
*
First
Last
Telephone Number
Work Number
NI Number
Occupation
Date of Birth
*
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Passenger 4
Name
*
First
Last
Telephone Number
Work Number
NI Number
Occupation
Date of Birth
*
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Credit Hire
Claiming VD
*
Yes
No
Claiming CH
*
Yes
No
Claiming STR
*
Yes
No
Client Vehicle Owner
*
Date of Birth
*
Address
Street Address
Address Line 2
ZIP / Postal Code
Replacement Vehicle Make, Model
*
Vehicle VRN
*
Hired From - Date
Hired To - Date
*
CH Pack Attached
*
Yes
No
I confirm that the following information is accurate to the best of my knowledge and I authorise Micheal&Sherms Solicitors to pursue my claim for damages for personal injury and loss.
*
Section Break
TOP
