@MMUNICA'ON WORKERS UNION

Size: px
Start display at page:

Download "@MMUNICA'ON WORKERS UNION"

Transcription

1 @MMUNICA'ON WORKERS UNION COMMUNICATION WORKBRS UNION LEGAL SERVICES DEPARTMENT Dear Colleague Form LS 18 I am sorry to lealn that that you have been involved in an accident. The Legal Services Depaftment of your Union will make every effort to ensure that you receive the best advice and assistance to enable you to recover any damages or benefits to which you may be entitled. PLEASE READ THIS ENTIIIE LETTER CAREFULLY. It contains impoltant information about your entitlements. Remember that your Union will assist you in accidents on and off duty. SECTION 1 All legal services are provided at the absolute discretion of the National Executive Council of the Union and/or its duly appointed Legal Officer. Assistance will only bc provided if you co-operate fully with your Local Branch Official, Union Headquarlers and the Uniou's appointed Solicitors. It is your responsibility to ensure that your Claim Form arives at the Union's Legal Services Department and that you receive a written acknowledgement. If you move fi'om the address given on the Claim Form you must notify, in writing, both Union Headquarters and your Local Branch Official of your new address. If you leave your employmcnt you rnust remain a member of the Union, failing r,vhich the Union cannot continuc to suirport your claim. Never voluntcer tbr rnedical letiremcnt. Seek erdvice fl'om CWU Fleaclquartcrs. SECTION 2 - CLAIM FOR D,,\hzIAGES To rccover darnages we mus;t provc that. somconc else was at tault. If yolr wish to purstic il claim for danrages please complrlc lhc attached I-S3 Form and return it to youl l,ocal Braitch Official asi s()o1.1 as possible. Your llranch Ofl'icial will scnd the form to us ancl we will wlitt: lo you at your honre address io acknowleclgc Leceipi of the forrn. S/e will then pass tlte 1.S3 Form to onc of oul Panel Solicitors to invcsiigato fhe r:ircnmstances of yo'rr acciclcnf ancl where possible pulslre a r;lairn lbt da,nages on youl' behalf. To assist with the funding of this sorvicc our Panel Soiicitorr; will pay a i'r;tblral lbt: to lhc Union ol':t; in rcspcct 1;f t:trery claim they accept. If you do not reccive an acl<norytretlgernent within 28 days, wi'ifo to Union F{eaclqrial'fct's, RtrMilMiSEIt if is your r'e:;po'nsitrilil:y to ensure that tire fcrna :rrrives in tlrc i,egal Services llepal'tment.

2 SECTION 3 - ACCIDENTS ON DUTY If you are injured as a result of an accident on duty you may be eligible to make a claim under the following three schemes. 1. PERSONAL INJURY THIRD PARTY CLAIMS Make sure your accident has been recorded in your Employers Accident Book. If it has not been, do so now. Complete Form LS3, as detailed above. Your claim will be passed on to the Union's Solicitors and they will investigate the merits of any claim. 2. INDUSTRIAL INJURIES BENEFIT This is a State Benefit. To rnake a claim you must register your accident with the Depaftment lbr Work and Pensions as an industrial injury. If you are still suffering the effects of your injuries 15 weeks after the date of the accident, apply to the Department for Work and Pensions for Disablement Benefit. Your Local Branch Official will help you to do this. Make sure you let your Local Branch Offlcial have a copy of any assessment that you receive from the Department for Work and Pensions. 3. (a) POST OF'FICtr PERSONAL ACCIDENT BENEFIT SCHEME (on DUry only) This is an in-house scheme provided by Royal Mail. All Employees can claim if their accident results in death or permanent physical injury. Claims must be registered with Royal Mail within 6 months of the accident. For further details contact your Local Branch Official. 3. (b) BT PERSONAL ACCIDENT INSURANCE SCI{EME (ON/OFF DUTY) This is an in-house scheme provided by BT. Claims are processed via an Insurance Company appointed by B'f and ciaims must be registered with them within two yezrrs of the accident. For further cletails contact your Local Branch Offlcial. s.lcjron_a - nccpbnr$ DUII Il you are injurecl as at result o['an accidcnt whilst oif cluty, inclucling road traffic accidents, please complete Claims Form LS3 as above anrl return it via your l,ocal Branch Official. si{g TroN_s -_g.bimin& J\rJ U-liIUS-.eWgN!3 At{UIlArrAqK s CHltMlI If y<tur injuries are as result o1'tt climinal ilss;trh, yoll mllst notify the Policc imrnedizrtely anri r;onrplete Claims Form [-S7 obtainablr: via youl L,ocal Branch O1flcial. Yci ri's sincerr:ly {,cgiil Scrviccs Departrncnt

3 Form LS 3 U Th e co m m u nicati on s u ni on NOT TO BE USED WHEN REPORTING OFFENCES TO BE CONSIDERED UNDER THE DRIVERS PROTECTION SCHEME / ROAD TRAFFIC ACT PROSECUTION CWU Ref: Branch: COMPI.ETE AS MUCH OF THIS FORM AS YOU CAN AND SIGN IT ON THE BACK PART 1: PERSONAL DETAILS - PLEASE COMPLETE EVERY SECTION Surname Address First Names Telephone No. Membership No. National lns. No. Postcode Date of Birth Employer: D BT tr RM Q Parcel Force E Counters tl Quadrant Q Other (specify) Were you D On Duty tr Off Duty PayrollNo'/ElNNo./oUCCode...'..,...'.'.'. ls the claim made on behalf of a Dependant?... f so; please complete this section: Dependant's surname Relation to Member First Nlames National lns. No. Ernployer's Nlame Date r:f Birth... f'}art 2: IISJURIES AND MEDICAL'I'Rf1"4l'nfi gilit Flave you fully recovered?... lf Yes, how iorrg clid recovery take?.'\re you nor,,/ carrying out your pre-accident clutics'? lf the injrrries are riisible, e.g. cuts, oruise ;,::c;arring; etc. pleerse tilr<c sonie photograph::. Fhotos attached tlyes l-l No l-i'ib follow

4 Name and address of injured person's General Praciitioner together with name and address of Hospital and Consultant if attended and outpatient No.... Date commenced sick leave and resumption of duty if known Has the accident been registered with the Department for Work and Pensions Yes D No fl Address of Department for Work and Pensions PART 3: THE ACCIDENT Date of accident Time of accident... AM/PM Where did the accident happen? Please provide full details of exactly how the accident happened; who do you think was to blame and why? What steps could your employer have taken to prevent the accident? Have any of these steps been introduced since the accident? lf the accident was caused by defective tools or equipment please give full details of the item and defect. The more information you give, the quicker your claim will be dealt with. lf there is not enough space here, please continue on a separate piece of paper and attach it securely to this form. Name and address of person/party considered responsible for accident. Were there any witnesses to the accident? Yes [l I'lo l.l \rvitnesses name'i and addresses... ;rk;asr: milkc sure 1.he slatemeni is signecl and da, i.er-i i:y ilrr; wiir:r:s::. {itatcrncirts rti;rchecl? Yes tl itjo l.l li Yi.:S, rt)v iltilitv

5 Fufther details (a) AGGIDENTS AT YOUR WORKPLACE ONLY Generally speaking, your claim is more likely to succeed if other people have had similar accidents before but your employer has done little or nothing to improve safety. lt does not matter whether anyone else has been injured. Please, therefore make enquiries of the people you work with to see if anyone else has had similar problems while performing their duties. lf so, please ask them to write down what happened to them, when it happened and whether they reporled it to their supervisor. Please make sure each statement is signed and dated by the person making it and, then, attach it to this form. Statements attached? Yes tr No D lf Yes, how many (b) RoAD TRAFFTC ACCTDENTS ONLY Was the accident reported to the police? Yes tr No tr lf Yes, how many Police Officer's name/number Police Station Were you driving: employer's vehicle D private vehicle E bicycle tr pedestrian Q Your vehicle registration no Your insurers (not brokers)... Your policy no.... Type of policy Fully comprehensive D Third party, fire, theft D Has your vehicle been repaired? Yes I No Q lf your vehicle has not been repaired please provide photos of the damage. Photographs attached? Yes tr No B To follow tr Please give address where the vehicle can be inspected Are storage charges being incurred Yes O No D Othcr,lrirler's narne and address Othcr rjriver's registration nrrmber Olhcr ciiivcr's insurance detail.s, including policy no.... Dicl lhe oihcr driver say anything to you about ihe accident? lf '/ES, urhai clici hclshe say?

6 (c) DOG BITE CASES ONLY Have you reported the attack io the Police? lf not, please do so immediately. This may help your case and also prevent other people being injured. Name and address of Owner of Dog Police Officer's name/number Police Station Do you know whether anyone else has been attacked? lf so, please provide details (d) DEFECTTVE PAVFMENT OI{LY lf you have not already done so, please take photographs of the defective pavement or other hazard that caused your accident. Please do this even if the defect has been repaired. Please measure exactly the height of the trip/ depth of pothole. Photographs and sketch plan attached Yes E No tr PART 4: YOUR SPECIAL ATTENTION IS DRAWN TO TTIIS CLAUSE, WHICH MUST BE SIGNED. I-EGAL COSTS I acknowledge that the Union will be responsible for any and all legal fees connected with the investigation and prosecution of rly case. However, I also acknowledge that I will be responsible for any and all legal fees connected with the investigation and prosecution of my case if: a) take the case out of the hands of the Union solicitors or, b) My Union membership (or that of the person on whom I am dependent) lapses or, c) I doliborateiy and fraudulenlly deceive the Union irr any rnaicrial lrarticular I acknowledge thai any such liability would only arise upon the occllrrence oi'one or more of the abo,re wrilten circrrmstanccs. tletails of the arrang;oments concerning legal costs ar; posied on the CWU website. I clcclarc llr;ii i have r'3acj lhe L$18 lettcr and to the best of my belief iiie informai:ioir given in this form is true. I deslre ihai riry casc be t:rl<en up hy th,; Union and its Soilcitors, whom I retain to act for me. l-j,;\ta ;r+l<) I'r:t:'llClrl AC r' ili,)ij I r,iride,'rs;i.rtrrci i.irai. in orc.ler i.o l,rlrr:;ue rrry claim the Union and its nornii'ateci Solicitors r,rrill have access ic pr.;rsonll (Ji]ri.l:,lrci s;cnsititrr; l.lersoni:. dala as defined in Seciions I and 2 or'ihr; t-i:ta Prctection Act i998. iircrci;y girrc rrry i.);(pi'css coitsoni lo i.lrc processing of ihat data by tht; C$/tJ anrl its norninated Solicitors Sr; fiii as il i:; nccessary for i.he.:onduct of my claim. \'bur :;i1.,1r-.ail!r:)...,;ir-;litr,ii t,irtr-;irtl'i sigitait,r-rr..!)arti;d lj.ricci

Legal Assistance (Personal Injury) Claim Form (NIPSA Member)

Legal Assistance (Personal Injury) Claim Form (NIPSA Member) Part 1 About your membership 1. Surname: Form LS2 Legal Assistance (Personal Injury) Claim Form (NIPSA Member) 2. Forename(s): (in full) 3. Branch No. 4. Membership No. 5. National Insurance No. For NIPSA

More information

Making a claim for compensation against Renfrewshire Council. Information and Claim Pack

Making a claim for compensation against Renfrewshire Council. Information and Claim Pack Making a claim for compensation against Renfrewshire Council Information and Claim Pack You must read these terms before completing the Public Liability Claim Form 1. If you make a claim through your own

More information

Personal Injury. We re on your side. Petherbridge Bassra. Your Local Solicitors

Personal Injury. We re on your side. Petherbridge Bassra. Your Local Solicitors Personal Injury We re on your side is a Bradford firm helping clients with cases close to home, nationally and internationally. These pages will tell you what we do and how we do it and naturally we will

More information

Road Traffic Accidents. Everything you need to know

Road Traffic Accidents. Everything you need to know Road Traffic Accidents Everything you need to know Families involved in a road traffic accident in this country and abroad can seek legal advice and assistance from EAD Solicitors. Anyone can seek legal

More information

Personal Injury Claim Form

Personal Injury Claim Form Personal Injury Claim Form In order that we may comply with the pre-accident protocol for personal injury claims as set out in the Civil Procedures Rules 1999 and to enable us to investigate your claim

More information

Personal Injury/Accident Claims Guidance

Personal Injury/Accident Claims Guidance Hutchesons Solicitors 17 Strathmore House East Kilbride Glasgow Lanarkshire G74 1LF Tel: 01355 224545 Fax: 01355 276565 E-mail: mail@hutchesonlaw.co.uk Personal Injury/Accident Claims Guidance 1 This is

More information

Making a claim against North Lanarkshire Council. Guidance Notes - Liability Claim Form

Making a claim against North Lanarkshire Council. Guidance Notes - Liability Claim Form Making a claim against North Lanarkshire Council Guidance Notes - Liability Claim Form It is important that you read these guidance notes before completing your claim form These are the terms and conditions

More information

Vehicle Damage Claim Form

Vehicle Damage Claim Form Vehicle Damage Claim Form In order that we may comply with the pre-accident protocol for property damage claims as set out in the Civil Procedures Rules 1999 and to enable us to investigate your claim

More information

Liability Claims Guidance Notes

Liability Claims Guidance Notes Liability Claims Guidance Notes It is important that you read and understand these guidance notes before When can a claim be made against the Council? completing the claim form To successfully claim compensation

More information

Your Accident Fact Kit

Your Accident Fact Kit Your Accident Fact Kit We hope you find our Accident Fact Kit helpful in the event of an accident. Please be sure to print multiple copies and keep them in the glove compartment of your vehicle in the

More information

Your Accident Fact Kit

Your Accident Fact Kit Your Accident Fact Kit We hope you find our Accident Fact Kit helpful in the event of an accident. Please be sure to print multiple copies and keep them in the glove compartment of your vehicle in the

More information

EWART PRICE SOLICITORS ROAD TRAFFIC ACCIDENTS - NOTES FOR CLAIMING FOR PERSONAL INJURY AND OTHER UNINSURED LOSSES

EWART PRICE SOLICITORS ROAD TRAFFIC ACCIDENTS - NOTES FOR CLAIMING FOR PERSONAL INJURY AND OTHER UNINSURED LOSSES E P EWART PRICE SOLICITORS ROAD TRAFFIC ACCIDENTS - NOTES FOR CLAIMING FOR PERSONAL INJURY AND OTHER UNINSURED LOSSES If you have been involved in a Road Traffic Accident as a driver or passenger we hope

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form

More information

Motor Vehicle Accidents

Motor Vehicle Accidents Motor Vehicle Accidents Crash!!! Oh no, now what? It is often hard to know what to do if you are involved in a motor vehicle accident. What rights and responsibilities do you have? And what actions, if

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form

More information

Application for Benefits under the Motor Accidents (Compensation) Act

Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for

More information

CRASHCARE Complete Claims Management

CRASHCARE Complete Claims Management CRASHCARE Complete Claims Management Embankment Chambers Embankment Road Plymouth PL4 9JJ Email: claims@crashcare.co.uk or visit us at www.crashcare.co.uk Telephone: 01752 264910 anytime or by Fax: 07092

More information

Please kindly quote the reference number on all correspondence returned

Please kindly quote the reference number on all correspondence returned Commercial Oxfordshire County Council Ron Groves House 23 Oxford Road Kidlington, Oxon OX5 2BP Dear Sir or Madam Highway enquiries: 0845 310 11 11 Please find enclosed details regarding claims for compensation

More information

MOTOR ACCIDENT REPORT (NOT FOR USE ON THEFT CLAIMS OR MOTOR TRADE)

MOTOR ACCIDENT REPORT (NOT FOR USE ON THEFT CLAIMS OR MOTOR TRADE) Insurance Company Limited MOTOR ACCIDENT REPORT (NOT FOR USE ON THEFT CLAIMS OR MOTOR TRADE) First Response Claims Line 0845 373 1300 Fax 020 7068 7740 Email claims@tradex.com www.tradex.com Policyholder

More information

Your Pocket Guide to Commercial Motor Claims

Your Pocket Guide to Commercial Motor Claims Your Pocket Guide to Commercial Motor Claims DRIVER CHECKLIST AT THE SCENE OF A MOTOR ACCIDENT If you are NOT injured, exit the vehicle: DO NOT ADMIT LIABILITY IF ANY party is injured - Call the emergency

More information

travel insurance travel claim report

travel insurance travel claim report claim report travel insurance travel CGU Insurance Limited ABN 27 004 478 371 An IAG Company Please retain this page for your information IMPORTANT Please read this before completing the report. Please

More information

Motor Accident Report Form

Motor Accident Report Form POLICYHOLDER DETAILS Policy Number: Name of Insured/Trading Title Claim Ref: Date of Birth: Email Occupation/Business Daytime Are you registered for VAT? Yes No If Yes please state VAT reg. no. PERSON

More information

Your Accident Fact Kit

Your Accident Fact Kit Your Accident Fact Kit We hope you find our Accident Fact Kit helpful in the event an accident. Don't forget to keep a pen with your kit. Keep the kit in your glove box, just in case you need it. It includes:

More information

Motor Vehicle Claim Form

Motor Vehicle Claim Form Motor Vehicle Claim Form Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form

More information

MOTOR VEHICLE ACCIDENT CLAIM FORM

MOTOR VEHICLE ACCIDENT CLAIM FORM MOTOR VEHICLE ACCIDENT CLAIM FORM Insurer: Policy No.: VAT Reg. No.: Insured Identity No.: Occupation: Phone No.: Vehicle Reg No.: Make: Tare: Gross Vehicle Mass: Kilometers: Date Purchased: Price Paid:

More information

Basildon Council - Motor Vehicle Claim Form

Basildon Council - Motor Vehicle Claim Form Basildon Council - Motor Vehicle Claim Form Please ensure you read the following information before completing this claims form and that you complete this form thoroughly, failure to complete the form

More information

Motor Accident Claim Form

Motor Accident Claim Form Motor Accident Claim Form Agricultural Commercial & Private Vehicles www.towergateunderwriting.co.uk Guidance Notes Most delays in settling claims arise because claim forms are not fully completed or requested

More information

GUIDE TO PERSONAL INJURY/ACCIDENT CLAIMS

GUIDE TO PERSONAL INJURY/ACCIDENT CLAIMS GUIDE TO PERSONAL INJURY/ACCIDENT CLAIMS At Richard Grogan & Associates we have Solicitors with significant experience and expertise who will advise and guide you through all matters relating to bringing

More information

Motor vehicle Accident report form

Motor vehicle Accident report form Motor vehicle Accident report form The issue of this form is not an admission of a claim Insurers maintain a motor insurance anti-fraud and theft register and exchange information with each other to prevent

More information

Motor Accident Report Form

Motor Accident Report Form Completing the claim form It is always important to notify your Insurer of a claim as soon as possible after an accident has occurred. Please therefore complete this form and return it to us within 14

More information

Frequently Asked Questions

Frequently Asked Questions Frequently Asked Questions Important Numbers Claims and Accident Helpline *We recommend you save this number to your mobile phone 0800 404 6016*(24 hours) Policy Changes 0844 800 0463 Quotes and Renewals

More information

Expiry Date. If you have selected Cheque please nominate payee

Expiry Date. If you have selected Cheque please nominate payee TRAVEL INSURANCE CLAIM FORM IMPORTANT: PLEASE READ BEFORE YOU COMPLETE THIS FORM 1. Please answer all questions and provide all relevant documentation to avoid delays with your We are unable to process

More information

Motor accident. Claim form. telephone 01 667 0666 fax 01 667 0644 website www.zurich.ie 06/08 FI 44766

Motor accident. Claim form. telephone 01 667 0666 fax 01 667 0644 website www.zurich.ie 06/08 FI 44766 Zurich House Ballsbridge park Dublin 4 telephone 01 667 0666 fax 01 667 0644 website www.zurich.ie ZURICH INSURANCE IRELAND LIMITED IS REGULATED BY THE FINANCIAL REGULATOR Claim form Motor accident 30

More information

Claims for compensation

Claims for compensation Claims for compensation Relating to an incident on the highway or footway which resulted in personal injury and/or damage to property Introduction This document is about compensation claims for incidents

More information

MOTOR VEHICLE ACCIDENT CLAIM FORM

MOTOR VEHICLE ACCIDENT CLAIM FORM MOTOR VEHICLE ACCIDENT CLAIM FORM Insurer: Insured Identity No.: Occupation: Phone No.: Vehicle Reg No.: Date Purchased: Make: Tare: Gross Vehicle Mass: Kilometers: Price Paid: Value: Year: Model: If the

More information

Workers Compensation claim form

Workers Compensation claim form Form Workers Compensation claim form STOP - this form is available to be filled in electronically on the NT WorkSafe web site www.worksafe.nt.gov.au. Fill the form in electronically then save a copy to

More information

CHURCH AND COMMERCIAL PROPERTY CLAIM FORM

CHURCH AND COMMERCIAL PROPERTY CLAIM FORM Methodist Insurance plc Brazennose House, Brazennose Street, Manchester M2 5AS Telephone 0161 833 9696 Facsimile 0161 833 1287 CHURCH AND COMMERCIAL PROPERTY CLAIM FORM CLAIM NUMBER: (Office use only)

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM The Issue of this Form is not an Admission of Liability by Insurers We understand the difficulties arising from your accident. Please complete and return this claim form as soon

More information

Motor Accident Claim Form

Motor Accident Claim Form Motor Accident Claim Form Agricultural Commercial & Private Vehicles www.towergateunderwriting.co.uk Guidance Notes Most delays in settling claims arise because claim forms are not fully completed or requested

More information

Compulsory Third Party Personal Injury Claim Notification

Compulsory Third Party Personal Injury Claim Notification Compulsory Third Party Personal Injury Claim tification To claim damages for personal injuries in a motor vehicle accident, please complete this form in BLOCK LETTERS 2. Do you have a solicitor acting

More information

Motor Accident FAQs. Motor

Motor Accident FAQs. Motor Motor Accident FAQs Motor FAQs Q. I have already reported my claim to you. When will I hear from you again? A. Depending on the accident, we may not need to contact you. This does not mean we are not dealing

More information

Motor Accident Notification Form (MANF)

Motor Accident Notification Form (MANF) Motor Accident tification Form (MANF) As prescribed under section 84(2)(a) of the Road Transport (Third-Party Insurance) Act 2008 For Compulsory Third-Party (CTP) Insurance Claims in the Australian Capital

More information

City of Cleveland Frank G. Jackson, Mayor

City of Cleveland Frank G. Jackson, Mayor City of Cleveland Frank G. Jackson, Mayor Department of Law Barbara A. Langhenry, Director 601 Lakeside Avenue, Room 106 Cleveland, Ohio 44114-1077 216/664-2800 Fax: 216/664-2663 www.cleveland-oh.gov Re:

More information

Claim for Personal Injury Compensation

Claim for Personal Injury Compensation FOR OFFICAL USE ONLY Ref No: Claim for Personal Injury Compensation (Please read the attached Information Leaflet carefully before completing this form) Please help us to assess your claim for compensation

More information

Personal Injury? What to Do?

Personal Injury? What to Do? Personal Injury? What to Do? 1 If you have been involved in a road traffic accident, an accident at work or an accident in a public place, you may be liable for a compensation! Every personal injury case

More information

Motor vehicle insurance claim form

Motor vehicle insurance claim form Motor vehicle insurance claim form Suva: 231 Waimanu Rd Phone: 331 1055 Fax: 330 3475 Nadi: Main Street Phone: 670 1451 Fax: 6701221 Important Notes To assist Dominion Insurance Limited ( us/our/we ) process

More information

O LEARY INSURANCE GROUP

O LEARY INSURANCE GROUP PART A - POLICYHOLDERS DETAILS Your name: Your Insurer + Policy Number: Your address: Your e-mail address (if any): Your occupation: Phone numbers Daytime: Evening: Mobile: Fax: Are you registered for

More information

Claim form Motor accident

Claim form Motor accident Claim form Motor accident 30 EAGLE STAR INSURANCE COMPANY (IRELAND) LTD CGL 25495 A member of the Zurich Financial Services Group www.eaglestar.ie Motor accident Policy number: Claim number: This form

More information

Motor Vehicle Claim Form

Motor Vehicle Claim Form Motor Vehicle Claim Form MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring

More information

Claim notification form

Claim notification form Before filling in this form you are encouraged to seek independent legal advice. Date sent / / Claim notification form Low value personal injury claims in road traffic accidents( 1,000-10,000) Are you

More information

APPLICATION FORM - PERSONAL INJURY (Do not use for fatal injuries)

APPLICATION FORM - PERSONAL INJURY (Do not use for fatal injuries) The Compensation Agency Royston House 34 Upper Queen Street Belfast BT1 6FD www.compensationni.gov.uk THE COMPENSATION Agency Reference number For official use only T1 Criminal Injuries Compensation Scheme

More information

Claim notification form

Claim notification form Before filling in this form you are encouraged to seek independent legal advice. Date sent / / Claim notification form Low value personal injury claims in road traffic accidents( 1,000-10,000) Are you

More information

Application for Benefits under the Motor Accidents (Compensation) Act

Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for

More information

APPLICATION FOR COMPENSATION FORM FOR A PERSONAL INJURY (Do not use this form for claims relating to fatal injuries)

APPLICATION FOR COMPENSATION FORM FOR A PERSONAL INJURY (Do not use this form for claims relating to fatal injuries) Compensation Services 6th Floor Millennium House 17-25 Great Victoria Street Belfast BT2 7AQ Telephone: 0300 200 7887 Criminal Injuries Compensation Scheme (2009) Made under the Criminal Injuries Compensation

More information

APPLICATION FOR COMPENSATION FORM FOR A PERSONAL INJURY (Do not use this form for claims relating to fatal injuries)

APPLICATION FOR COMPENSATION FORM FOR A PERSONAL INJURY (Do not use this form for claims relating to fatal injuries) The Compensation Agency Royston House 34 Upper Queen Street Belfast BT1 6FD www.compensationni.gov.uk THE COMPENSATION Agency Reference number For official use only T4 Criminal Injuries Compensation Scheme

More information

How to make a personal injury claim

How to make a personal injury claim A publication by Cute Injury How to make a personal injury claim A CLEAR AND CONCISE GUIDE TO THE PERSONAL INJURY CLAIMS PROCESS We provide professional and impartial advice from the outset and throughout

More information

Accidents. Added motoring peace-of-mind. This is your AA Added Value for. Introduction. Membership Handbook

Accidents. Added motoring peace-of-mind. This is your AA Added Value for. Introduction. Membership Handbook Added motoring peace-of-mind This is your AA Added Value for Accidents Membership Handbook Introduction As a Member of the AA, you know you get so much more than the average roadside assistance service

More information

Community Underwriting Motor Claim Form

Community Underwriting Motor Claim Form Community Underwriting Motor Claim Form About the Insurer Calliden Insurance Limited (Calliden) (ABN 47 004 125 268), is a public company incorporated in Australia. It is authorised under the Australian

More information

Motor Vehicle Accident Report Form

Motor Vehicle Accident Report Form Motor Vehicle Accident Report Form 1300 725 788 Your Car, Your Choice Know Your Rights Service & Quality Guaranteed One Call Does It All Owner s Particulars (PLEASE COMPLETE IN BLOCK LETTERS) Full Name

More information

Citibank Travel Insurance Claim Form

Citibank Travel Insurance Claim Form ACE Insurance Limited ABN 23 001 642 020 AFSL. 239687 Level 1, 51 Berry Street rth Sydney NSW 2060 Australia PO Box 403 rth Sydney NSW 2059 Australia 1800 305 422 (02) 8912 9704 (02) 9231 3697 +61 2 8912

More information

Accident Report Form Personal Injury Claims

Accident Report Form Personal Injury Claims Reference. Please read the attached Guidance tes before completing this form. In addition to completing the Claim tification Form (PL1), please complete this Accident Report Form. The additional information

More information

Motor Accident Claim Form Insured Section

Motor Accident Claim Form Insured Section Motor Accident Claim Form Insured Section Date Insured Name Insured Licence Code Licence : Date of Issue Insured Id Policy Insured Address Suburb Town Province Code Contact Person Landline Number Fax Number

More information

CTP PERSONAL INJURY CLAIM INFORMATION KIT

CTP PERSONAL INJURY CLAIM INFORMATION KIT CTP PERSONAL INJURY CLAIM INFORMATION KIT Contents Your road to recovery starts here What should I do now? 4 What am I covered for? 5 How is my claim processed? 6 Problems or Disagreements 8 Finalising

More information

CLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle

CLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle Notice of Accident CLAIM FORM A To be completed by the registered operator/ owner or driver of the vehicle If you have suffered Personal Injury resulting directly from this motor accident and wish to claim

More information

Motoring Legal Solutions

Motoring Legal Solutions Motoring Legal Solutions Policy Summary This summary does not contain the full terms and conditions of this insurance contract; these can be found in the Policy document What is Motoring Legal Solutions?

More information

Key Policy Information

Key Policy Information Key Information Inside you ll find a summary of your car insurance tescobank.com Tesco Bank Car Insurance Key Information This is a summary of cover available under Tesco Bank Car Insurance. It does not

More information

Motor Accident Report Form

Motor Accident Report Form Motor Accident Report Form Tel: 01423 876000 Rural Insurance Group Limited The Lenz Hornbeam Park Harrogate HG2 8RE Fax: 01423 874127 INSURED Motor Accident Report Form Policy. Name Home Tel.. Work Tel..

More information

Tradewise Insurance Company Ltd

Tradewise Insurance Company Ltd Tradewise Insurance Company Ltd MOTOR ACCIDENT REPORT FORM Ensure all sections of this form are completed fully. Also note that any attempt to defraud Underwriters will result in criminal prosecution.

More information

Parliament House, 9/10 Georges Quay, Cork City, Ireland Phone: +353-(0)21-4963400 / 4271006 Email: maharvey@martinharvey.ie

Parliament House, 9/10 Georges Quay, Cork City, Ireland Phone: +353-(0)21-4963400 / 4271006 Email: maharvey@martinharvey.ie Parliament House, 9/10 Georges Quay, Cork City, Ireland Phone: +353-(0)21-4963400 / 4271006 Email: maharvey@martinharvey.ie COMPENSATION CLAIMS: If someone injuries you and it is not your fault, you are

More information

Motor Vehicle Insurance Claim. Insured

Motor Vehicle Insurance Claim. Insured Suite 5 & 6 156 Oxford St, Leederville WA 6007 PO Box 495, Leederville WA 6903 Freecall: 1800 776 747 Facsimile: 1800 194 525 Email: info@mynfib.com.au ABN 23 108 296 064 National Franchise Insurance Brokers

More information

Motor Vehicle Insurance Claim

Motor Vehicle Insurance Claim Motor Vehicle Insurance Claim The supply or acceptance of this form is not an admission of liability on the part of the insurer. Please complete ALL sections of this claim form. Unless specifically arranged

More information

Types of cover. What is an insurance excess? What affects the price of my motor insurance? How to shop around for the best deal

Types of cover. What is an insurance excess? What affects the price of my motor insurance? How to shop around for the best deal The Consumer CouncilThe Consumer Council Contents Types of cover What is an insurance excess? What affects the price of my motor insurance? How to shop around for the best deal Tips for cutting the cost

More information

Personal Accident and Sickness Claim Form

Personal Accident and Sickness Claim Form Please return claim form to: Corporate Services Network 2 / 280 George Street Sydney NSW 2000 Ph: +61 2 8256 1770 Fax: +61 2 8256 1775 E-mail: claims@csnet.com.au Employer: Claimants Name: Job Title: Work

More information

ACCIDENT-@LL CLAIM FORM (page 1) Name:.. Address:...Post Code:... Sex M/F D.O.B. Age:... Tel:.. Mobile:. Occupation:. Name & Address of Employer:..

ACCIDENT-@LL CLAIM FORM (page 1) Name:.. Address:...Post Code:... Sex M/F D.O.B. Age:... Tel:.. Mobile:. Occupation:. Name & Address of Employer:.. CLAIM FORM (page 1) DRIVER DETAILS Address:........Post Code:..... Sex M/F D.O.B. Age:... Tel:.. Mobile:. Occupation:. Name & Address of Employer:.. NI No:. CAR DETAILS Registration No:... Make & Model:...

More information

Can the TAC help you?

Can the TAC help you? Can the TAC help you? The Transport Accident Commission (TAC) pays for the reasonable cost of treatment and support services for people injured in transport accidents. You may be eligible to have medical

More information

For Employers Driving at Work Policy

For Employers Driving at Work Policy For Employers Driving at Work Policy Road Safety You may already have a driving for work policy within your health and safety policy or as a separate document. If you do, it may be useful to check that

More information

L.E. LAW INFORMATION SHEET NO. 11 GUIDE TO PERSONAL INJURY CLAIMS

L.E. LAW INFORMATION SHEET NO. 11 GUIDE TO PERSONAL INJURY CLAIMS LE Law Services Ltd 127 High Road Loughton Essex IG10 4LT Telephone: 020 8508 4961 Facsimile: 020 8508 6359 www.lelaw.co.uk L.E. LAW INFORMATION SHEET NO. 11 GUIDE TO PERSONAL INJURY CLAIMS 1. Introduction

More information

PLEASURE CRAFT / HULL CLAIM FORM

PLEASURE CRAFT / HULL CLAIM FORM PLEASURE CRAFT / HULL CLAIM FORM INSURANCE BROKERS The Issue of this Form is not an Admission of Liability by Insurer Policy # : Claim # : Please complete and return this claim form as soon as possible,

More information

Accident Reporting & Investigation Policy and Guidance

Accident Reporting & Investigation Policy and Guidance Accident Reporting & Investigation Policy and Guidance INTRODUCTION Torbay Council is committed to providing an environment which is as healthy and as safe as possible for its staff, visitors and the local

More information

VEHICLE ACCIDENT CLAIM FORM

VEHICLE ACCIDENT CLAIM FORM Please help us to help you by: completing all relevant questions in full as this can avoid the need for further enquiry and possible delay in settling your claim signing and dating page 7 of this form

More information

Motor Legal Care Terms and Conditions

Motor Legal Care Terms and Conditions Motor Legal Care Terms and Conditions The cover provided under this notice is in addition to your Breakdown cover and should be read together with your existing terms and conditions. RAC Motor Legal Care

More information

Claim for Compensation for a Work-related death

Claim for Compensation for a Work-related death SRC184(Feb2008) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) for the

More information

Policy Summary. Inside you ll find a summary of your car insurance. tescobank.com

Policy Summary. Inside you ll find a summary of your car insurance. tescobank.com Summary Inside you ll find a summary of your car insurance tescobank.com Tesco Bank Car Insurance Summary This is a summary of cover available under Tesco Bank Car Insurance. It does not include all the

More information

If you have an accident call us straightaway on 0844 251 0190. For our joint protection, calls may be recorded and/or monitored. Your policy summary

If you have an accident call us straightaway on 0844 251 0190. For our joint protection, calls may be recorded and/or monitored. Your policy summary If you have an accident call us straightaway on 0844 251 0190. For our joint protection, calls may be recorded and/or monitored. Your policy summary Your policy summary 2. Your policy summary 5. Important

More information

HIGHWAY INCIDENT CLAIM FORM Please read the information provided before completing this form

HIGHWAY INCIDENT CLAIM FORM Please read the information provided before completing this form Page 1 of 6 S HIGHWAY INCIDENT CLAIM FORM Please read the information provided before completing this form Please report any dangerous defects to the Surrey Highways team as soon as possible by logging

More information

DASDRIVE ULTIMATE LEGAL PROTECTION KEY FACTS BROCHURE. Act quickly after an accident and call us now on

DASDRIVE ULTIMATE LEGAL PROTECTION KEY FACTS BROCHURE. Act quickly after an accident and call us now on DASDRIVE ULTIMATE LEGAL PROTECTION KEY FACTS BROCHURE Act quickly after an accident and call us now on 0800 783 6066 2 DASDRIVE ULTIMATE If you ve been unfortunate enough to have been involved in a motor

More information

Motor Vehicle Insurance Claim. Insured

Motor Vehicle Insurance Claim. Insured INSURANCE BROKERS 22 Welsford Street, Shepparton PO Box 1377, Shepparton VIC 3632 www.ggib.com.au Phone (03) 5821-7777 Fax (03) 5822-2916 Email ggib@ggib.com.au ABN 52 858 454 162 AFS 237 533 Motor Vehicle

More information

BICYCLE NEW SOUTH WALES PERSONAL INJURY CLAIM FORM

BICYCLE NEW SOUTH WALES PERSONAL INJURY CLAIM FORM Office use only Policy Number: AN A044041 PAD Claim Number: BICYCLE NEW SOUTH WALES PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR BICYCLE NEW SOUTH WALES INC V-Insurance Group Pty Ltd V-Insurance Group

More information

Motor Fleet. Policy Summary. coveainsurance.co.uk. Registration and Regulatory Information

Motor Fleet. Policy Summary. coveainsurance.co.uk. Registration and Regulatory Information Motor Fleet Policy Summary Motor Fleet insurance is for companies, sole traders or partnerships operating a fleet of 3 to 25 vehicles comprising of cars and commercial vehicles used for the business of

More information

Motor Accidents Compensation Amendment Bill 2009

Motor Accidents Compensation Amendment Bill 2009 First print New South Wales Motor Accidents Compensation Amendment Bill 009 Explanatory note This explanatory note relates to this Bill as introduced into Parliament. Overview of Bill The objects of this

More information

Motorcycle Policy Summary and Important Information

Motorcycle Policy Summary and Important Information Motorcycle Policy Summary and Important Information This is a summary of the policy and does not contain the full terms and conditions of the cover, which can be found in the policy documentation. It is

More information

MOTOR TRADE CLAIM FORM

MOTOR TRADE CLAIM FORM Insurance Company Limited MOTOR TRADE CLAIM FORM First Response Claims Line 0845 373 1300 Fax 020 7068 7740 Email claims@tradex.com www.tradex.com Policyholder s Name Company Name Policy No. (cover note

More information

Questionnaire Cornwell-Type Claims

Questionnaire Cornwell-Type Claims Sensitive: Personal once completed Questionnaire Cornwell-Type Claims Please complete all sections of this form and enter N/A in any section that is not applicable to indicate that the question has been

More information

GIO Workers Compensation Australian Capital Territory

GIO Workers Compensation Australian Capital Territory GIO Workers Compensation Australian Capital Territory Employee s claim form Employer s policy number: Complete all questions fully and accurately, to ensure accurate decisions can be made about your claim.

More information

Part 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1.

Part 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1. Form Workers compensation claim form Part 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1. Notify your employer of your injury or disease

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM (If there is not enough room on this form for your answers, please attach a separate sheet, indicating the Section and Question you wish to complete.) Please lodge your claim to

More information

DAWES MOTOR INSURANCE MOTORCYCLE CLAIM FORM IMPORTANT NOTICES

DAWES MOTOR INSURANCE MOTORCYCLE CLAIM FORM IMPORTANT NOTICES DAWES MOTOR INSURANCE MOTORCYCLE CLAIM FORM P.O. Box 2717 Taren Point NSW 2229 Phone: 1300 188 299 Fax: 1300 662 215 claims@dawes.com.au To ensure prompt attention to your claim, please complete this form

More information