1. Statement on behalf of: Claimant 2. Statement made by: Tony Martin 3. No of Statement: First 4. Exhibits: 5. Date: 28th July 2oo8 TONY MARTIN

Size: px
Start display at page:

Download "1. Statement on behalf of: Claimant 2. Statement made by: Tony Martin 3. No of Statement: First 4. Exhibits: 5. Date: 28th July 2oo8 TONY MARTIN"

Transcription

1 RTA - CLIENT STATEMENT 1. Statement on behalf of: Claimant 2. Statement made by: Tony Martin 3. No of Statement: First 4. Exhibits: 5. Date: 28th July 2oo8 IN THE COUNTY COURT Claim No: BETWEEN TONY MARTIN -And- Claimant Defendant STATEMENT OF CLAIMANT MR. TONY MARTIN I Tony Martin of 89 Brent Close, Ladby, Leicester, LE1 8XX, state as follows:; 1. I am 23 years of age having been born on the 23'd January I am employed on a full time basis for approximately 18 months at a cheque processing centre for The Bank of Scotland. 3. I make this statement from my own knowledge unless otherwise stated and where otherwise stated to the best of my knowledge and belief. 4. I can confirm that I am the Claimant in this action and live at the above address with my parents. 5. I make this statement in relation to a road traffic accident that I was involved in on the 22"d August 2007 at approximately 09:00 hrs, with an articulated lorry, I do not know the registration number, which was being driven by the Defendant. 6. At the time of the accident I had been driving for approximately one month, having passed my driving test in July My driving licence number is MAR

2 7. I hold a full driving licence with 3 penalty points. These were for a TS10 offence and were added to my licence in April At the time of the accident I was driving my vehicle, a white Nissan Sunny 1400cc motor vehicle, registration number M I was covered to drive the vehicle on a third party basis only. 10. I had owned this vehicle for approximately one month prior to the accident. I had regularly driven it in this time and was very comfortable with the controls. 11. l drive a round trip of approximately 50 miles per day to my workplace. 12. My mother, Mrs Gwenda Martin, was my front seat passenger. 13. I am familiar with the route that I took at the time of the accident; I was taking my mother to work and had used the same route on a number of occasions since passing my driving test. 14. I can confirm that at the time of the accident we were wearing our seatbelts as is required by law. 15. I do not need to wear glasses when driving my vehicle. I had not been drinking alcohol or taking any medication that may have affected my ability to drive. 16. I was not smoking or attempting to smoke; indeed I do not smoke. 17. I was not using a mobile phone and was not distracted in any other way. I can confirm that although there was a radio in my vehicle it was not working.

3 18. lwas not in any particular hurry, my mother starts work at approximately 09:00hrs and at the time of the accident I was approximately 5 miles away from her workplace. 19. The weather was dry and sunny with good visibility. The roads were dry. 20. There were no road works or other obstructions in the road at that time. 21. At approximately 08:00 hrs on 2nd August 2007 was travelling on the A44 and heading towards Glenfield Roundabout, Leicester. 22. On the approach to the roundabout the slip road consists of two lanes widening to three lanes prior to the junction. 23. The nearside lane is marked with a directional arrow for vehicles turning left only. 24. The centre lane is marked with a directional arrow for vehicles travelling straight ahead and for turning right on the roundabout. 25. The offside lane is marked with a directional arrow for vehicles turning right only. 26. lt was my intention to turn left at the roundabout; I was correctly positioned and stationary in the nearside lane; I was first in line at the give way markings and I do not recall anything being behind me. 27. The Defendant was positioned in the middle lane and there were no other vehicles in front of the Defendant's vehicle. 28. I did notice that the cab of this vehicle was angled slightly to the left although I do not recall seeing any indicator lights illuminated.

4 29. The Defendant started to make his manoeuvre onto the roundabout and after checking that it was safe to do so I started to make my manoeuvre onto the roundabout. 30. The Defendant's vehicle started to come across the front of my vehicle, I stopped, the Defendant's vehicle continued to turn left impacting with the offside front of my vehicle. 31. There was nothing that I could do as the Defendant's vehicle pushed me off the road and into a ditch at the side of the road. 32, Although restrained by our seatbelts the force of the impact caused us to be thrown sideways in our seats. 33. I was immediately shocked and stunned and needed to take a few moments to gather my thoughts. I was initially shaken and trembling slightly for approximately one hour. 34. I checked that my mother was alright before making my way out of my vehicle. 35. My mother was shocked and stunned and remained sitting in the vehicle, she said that she had hurt her neck. 36. Following the impact the Defendant had continued to drive his vehicle around the roundabout before stopping and parking along the kerbside. 37. I walked over to the Defendant who was still sitting in his cab. I started to speak to the Defendant however he looked at me in apology and shrugged his shoulders before starting to speak himself. 38. The Defendant was talking in a foreign language, possibly Polish. I could not understand what he was saying and I do not think that he could understand me.

5 39. I contacted my father and the emergency services to inform them of the accident. 40. An ambulance arrived at the scene and my mother was examined by paramedics before being transported by ambulance to the Accident and Emergency Department of Leicester Royal infirmary, Infirmary Square, Leicester, LE1 5\ Al/. 41. The police had also arrived at the scene and attempted to get details from the Defendant. 42. The two officers in attendance were PC211 and PC194. lwas given a police incident number of The police checked the Defendant's vehicle before allowing him to leave the scene. 44. I can confirm that nobody was breathalysed at the scene. 45. When the police returned to speak to me and to take my details they informed me that the Defendant had somehow managed to explain to them that he was not familiar with the UK road layout. 46. My vehicle was undriveable as the result of the damage sustained which was to the front offside door and wing which had been crushed inwards. 47. My uncle has a garage based in Loughborough. I contacted him and arranged for my vehicle to be transported from the scene and back to my home. 48. Approximately 25 minutes following the accident and while I was waiting for my vehicle to be recovered I can confirm that there was another accident at the roundabout. 49. My vehicle was recovered from the scene and I along with my vehicle were transported back home.

6 50. I can confirm that no witnesses made themselves known to me whilst I was at the scene. 51. On my return home my father was waiting for me. I had started to experience symptoms of pain at the back of my neck. 52. My father took me to the accident and emergency department of Leicester Royal infirmary to be checked over before taking me to work. 53. Although I was suffering from some pain in my neck I managed to complete my day at work before returning home. 54. I took over the counter pain relieving analgesics and went to bed. 55, The following morning and after suffering a very painful, restless and uncomfortable night I attended the Leicester Medical Centre, Leicester, LE121AB. 56. lwas examined and given advice before being discharged. 57. I can confirm that the pain and stiffness experienced at the back of my neck increased in intensity for approximately two days following the accident and were at the most severe for approximately one week before gradually starting to ease. 58. My painful neck symptoms had eased significantly after two months and by December 2007 were approximately 80-85% resolved. 59. The day following the accident my right wrist had become painful and there was slight swelling caused. This was uncomfortable for me for approximately two days and had completely resolved within two weeks.

7 60. Approximately two days following the accident I had started to experience symptoms of pain and discomfort between my shoulder blades. 61. This radiated down centrally and took approximately two weeks before reaching a peak. 62. I can confirm that I experienced almost constant symptoms of pain and discomfort in my back. 63. Although I would describe these symptoms as a moderate pain they did last for approximately two months before gradually starting to ease. 64. By December 2007 the symptoms to my back were approximately 70% resolved. 65. As a result of injuries sustained in the accident I refrained from work for approximately 14 days. Following this time I had to return. 66. I am employed as an agency worker and if I had taken any longer off work there was a strong possibility that I would have lost my job. 67. A few days following my visit to the walk in centre I attended my own GP surgery, Leicester Medical Centre. Leicester. LE1 2EE. 68. I was examined and advised to keep moving around but not to lift any heavy objects. 69. Prior to the accident I was a member of a local gym and would attend approximately once a week. I also performed martial arts. I was further advised to refrain from participating in these activities. 70. I can confirm that since being involved in the accident and as a result of injuries sustained I have not returned to the gym.

8 71. I have been performing martial arts for approximately 4-5 years and it was a big part of my life. 72. I had achieved the status of brown belt and was working towards my black belt when I was involved in the accident. 73. Although I tried to return to martial arts, due to a constant fear of aggravating symptoms and the possibility of causing further damage, apart from doing partial training at home, which seemed to be alright initially, however I did experience an aggravation to my painful symptoms a few days following the training. 74. I have now completely refrained from participating in this much loved activity. 75. Prior to the accident my father had bought me a Go Kart for approximately f400. I used to use it every Sunday. 76. Following the accident I was unable to use the Go Kart and subsequently sold it. 77. In addition to my physical injuries I also sutfered psychologically which affected my driving. 78. lt was approximately 3-4 weeks before I felt comfortable enough to return to driving despite having access to my father's vehicle if I had wanted to. 79. I relied mainly on my father to transport me to and from work on a daily basis for the two week period following my return to work. 80. On the occasions when my father was unable to transport me I would have to use the bus service which would add an extra approximately minutes to my working day each time.

9 81. For approximately 2 months following my return to driving I was very anxious and wary. 82. I was particularly frightened of the possibility of being involved in another accident. 83. I have continued to experience symptoms of anxiety whenever travelling close to articulated Lorries. 84. lf I drive for any longer period than approximately 25 minutes at once I continue to experience an aching sensation in my lower back. 85. lf I know that I am going to travel for this length of time I take a cushion from home and although this is not very comfortable and I prefer to drive without having to rely on a cushion for my back I only use it in an attempt to ease my symptoms of back ache. 86. When at work and throughout the working day the main aspect of my work can involve standing at a machine for approximately 6-7 hours at a time. I have to take regular 5 minute breaks away from the machine and rest before returning. 87. I particularly notice the aching at the end of the working day. 88. At other times I can be working at a desk, and experience symptoms of pain and discomfort in my upper back moving down into my lower back. 89. This is usually as a result of sitting in a fixed position for any length of time which is over approximately one hour. 90. I tend to frequently stand up and walk around to stretch my muscles when this happens. 91. I took the advised pain relieving analgesics frequently in an attempt to ease the severity of my continuing symptoms of pain and discomfort.

10 92. t was examined on 3'd March 2008 by Dr D. Octor who was instructed by my solicitor, I have read and agree with his report a copy of which is with my solicitor. 93. In this report I was encouraged to swim approximately 2-3 times a week in an attempt to improve my symptoms. I can confirm that I have been attending the local swimming baths a few times each month and have noticed some improvement to my symptoms. 94. lt was recommended that I attend sessions of physiotherapy in a further attempt to improve my symptoms. I can confirm that I did attend for two sessions approximately 3-4 months ago. I did notice an improvement. 95. I now need to return to my GP to be re referred and am currently in the process of trying for this. 96. lf the referral through my GP takes too long before I get an appointment I will look to paying for the physiotherapy privately. 97. I was able to confirm that I was involved in a further non fault road traffic accident in December 2007 in which the symptoms that I had originally sustained and which had been at this point approximately 80o/o resolved, where actually further aggravated by this second accident. 98. I believe the Claimant was responsible for the accident for not being correctly positioned at the roundabout for the direction that he intended to take and for mot making proper observations before making his manoeuvre.

11 STATEMENT OF TRUTH: I have read the above Statement. It is a true and accurate record: Signed: Date:

-and- WITNESS STATEMENT OF JOHN HENRY RHODE-CLAIMS. I, John Henry Rhode-Claims of 25 Whiplash Crescent, Crashtown, Wreckageshire, WC0 0KK will

-and- WITNESS STATEMENT OF JOHN HENRY RHODE-CLAIMS. I, John Henry Rhode-Claims of 25 Whiplash Crescent, Crashtown, Wreckageshire, WC0 0KK will 1. Statement on behalf of: Claimant 2. Statement made by: John Henry Rhode-Claims 3. No of Statement: First 4. Exhibits: 5. Date: 11 th July 2011 IN THE NO CLAIMS COUNTY COURT Claim No: NT3078P BETWEEN

More information

Personal Injury Medical Report on. Joan Smith DOB 24.12.74. Reference

Personal Injury Medical Report on. Joan Smith DOB 24.12.74. Reference Personal Injury Medical Report on Joan Smith DOB 24.12.74 Reference by Dr. A.R.Feltbower MB BChir DRCOG AFOM General Medical Practitioner Westminster Road Medical Services Ltd 41 Westminster Road Coventry.

More information

How To Live With A Broken Neck

How To Live With A Broken Neck MEDICAL REPORT THIS IS A REPORT TO THE COURT BASED UPON THE HISTORY OF THE INJURIES SUSTAINED BY THE CLAIMANT, THE TREATMENT, CONDITION AND PROGNOSIS. NAME: ADDRESS: Travelanx Whiplash Manchester DOB:

More information

Auto Accident Questionnaire

Auto Accident Questionnaire Auto Accident Questionnaire Patient s Name: Date Of Accident: Date: Social History: (please complete the following, check all boxes that apply) Are you: Married Single Divorced Widowed # of Children: #

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

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

Medical Report. Prepared for the Court. Section A - Claimant's details. Occupation. Address 1.1. Has photo ID been confirmed?

Medical Report. Prepared for the Court. Section A - Claimant's details. Occupation. Address 1.1. Has photo ID been confirmed? Medical Report Prepared for the Court Section A - Claimant's details Claimants full name Mr Forename Surname Date of Birth Occupation Address Librarian Address, Address, Town, Post Code. 1.1 Has photo

More information

Claim notification form (Form RTA1)

Claim notification form (Form RTA1) Date sent / / Claim notification form (Form RTA1) Low value personal injury claims in road traffic accidents( 1,000-10,000) Before filling in this form you are encouraged to seek independent legal advice.

More information

THE CHARTERED INSTITUTE OF LEGAL EXECUTIVES UNIT 3 THE LAW AND PRACTICE RELATING TO ROAD TRAFFIC ACCIDENTS *

THE CHARTERED INSTITUTE OF LEGAL EXECUTIVES UNIT 3 THE LAW AND PRACTICE RELATING TO ROAD TRAFFIC ACCIDENTS * 15 January 2015 Level 4 THE LAW AND PRACTICE RELATING TO ROAD TRAFFIC ACCIDENTS Subject Code L4-3 THE CHARTERED INSTITUTE OF LEGAL EXECUTIVES UNIT 3 THE LAW AND PRACTICE RELATING TO ROAD TRAFFIC ACCIDENTS

More information

Auto Accident Description

Auto Accident Description Automotive Accident Form Billing Information Patient name: Date of injury: Time of injury: AM PM City and street where accident occurred: What is the estimated damage to your vehicle? $ Do you have automobile

More information

Report of a Complaint Handling Review in relation to Central Scotland Police

Report of a Complaint Handling Review in relation to Central Scotland Police Case reference: PCCS/00410/12/CSP June 2013 Report of a Complaint Handling Review in relation to Central Scotland Police under section 35(1) of the Police Public Order and Criminal Justice (Scotland) Act

More information

POLICY FOR HEALTH SAFETY AND WELFARE

POLICY FOR HEALTH SAFETY AND WELFARE POLICY FOR HEALTH SAFETY AND WELFARE PART C ARRANGEMENTS Section 34 DRIVING AT WORK (GREY FLEET) May 2010 1 CONTENTS 1.0 INTRODUCTION 1.1 Statutory Requirements 1.2 Safe System of Work 2.0 ROLES AND RESPONSIBILITIES

More information

Claim notification form (RTA1) Low value personal injury claims in road traffic accidents ( 1,000-25,000)

Claim notification form (RTA1) Low value personal injury claims in road traffic accidents ( 1,000-25,000) Date sent / / Claim notification form (RTA1) Low value personal injury claims in road traffic accidents ( 1,000-25,000) Before filling in this form you are encouraged to seek independent legal advice.

More information

SAMPLE POLICY ON THE USE OF COMPANY VEHICLES. 1. Purpose: To set out policy of The Company with regard to the use of company vehicles.

SAMPLE POLICY ON THE USE OF COMPANY VEHICLES. 1. Purpose: To set out policy of The Company with regard to the use of company vehicles. SAMPLE POLICY ON THE USE OF COMPANY VEHICLES Policy No: Edition No: Issued by: Issue Date: Effective From: 1. Purpose: To set out policy of The Company with regard to the use of company vehicles. 2. Scope:

More information

Medical Report Prepared for The Court on

Medical Report Prepared for The Court on Medical Report Prepared for The Court on Mr Sample Report Claimant's Address Claimant's Date of Birth Instructing Party Instructing Party Address Instructing Party Ref Solicitors Ref Corex Ref 1 The Lane

More information

Inquiry form - Motor Accident Page 1

Inquiry form - Motor Accident Page 1 Inquiry form - Motor Accident Page 1 1. Personal Details i. Full name Date of Birth i Residential address Documents to bring If relevant in your situation : diagram or photo of accident site, police report

More information

Report of a Complaint Handling Review in relation to Tayside Police

Report of a Complaint Handling Review in relation to Tayside Police Case reference: PCCS/00038/12/PF TP October 2012 Report of a Complaint Handling Review in relation to Tayside Police under section 35(1) of the Police Public Order and Criminal Justice (Scotland) Act 2006

More information

How to treat your injured neck

How to treat your injured neck How to treat your injured neck Exceptional healthcare, personally delivered Your neck is made up of a number of bones bound together by strong discs and ligaments. It is also protected by strong muscles.

More information

TRANSPORTATION POLICY

TRANSPORTATION POLICY TRANSPORTATION POLICY Contents 1 NQS... 2 2 National Regulations... 2 3 Aim... 2 4 Related Policies... 2 5 Implementation... 2 6 General Transport Guidelines... 4 7 Guidelines for Seatbelts and Restraints...

More information

Death in the line of duty...

Death in the line of duty... F-33 Fire Fighter Fatality Investigation A Summary of a NIOSH fire fighter fatality investigation Death in the line of duty... May 25, 2000 Motor-Vehicle Incident Claims the Life of a Volunteer Fire Fighter

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

Auto Accident/Personal Injury Information

Auto Accident/Personal Injury Information Auto Accident/Personal Injury Information Patient s Name: Today s Date: Personal Injury Information Date of Accident: Time of Accident: am/pm Did police arrive on scene? [ ] Yes [ ] No Is there a report?

More information

MEDICAL REPORT AB/12/FGH/679 SOLICITOR'S REF. INSTRUCTIONS FROM Jones and Jones Solicitors. John Finton CLIENT'S NAME

MEDICAL REPORT AB/12/FGH/679 SOLICITOR'S REF. INSTRUCTIONS FROM Jones and Jones Solicitors. John Finton CLIENT'S NAME MEDICAL REPORT SOLICITOR'S REF AB/12/FGH/679 INSTRUCTIONS FROM Jones and Jones Solicitors CLIENT'S NAME ADDRESS John Finton 98 Prescot Road, Macclesfield, Cheshire DOB 10 January 1978 DATE OF ACCIDENT

More information

AHIS Road safety project Student Council THINK!

AHIS Road safety project Student Council THINK! AHIS Road safety project Student Council 2013 THINK! Today, we drive safer cars on safer roads; decades of advertisements and public information campaigns have made most of us safer drivers. Improvements

More information

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE & CHECKLIST

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE & CHECKLIST EQUILAW Solicitors Ph: 02 6542 5566 Market House 4 Market Street Muswellbrook NSW 2333 Fax: 02 6543 4397 info@equilaw.com.au equilaw.com.au MOTOR VEHICLE ACCIDENT QUESTIONNAIRE & CHECKLIST Bring this completed

More information

Driver Card. Driver Helpline. Your. Your

Driver Card. Driver Helpline. Your. Your Your Driver Card Dispatched before the delivery of the new vehicle, the driver card features a helpline number, your customer identification number (where applicable) and details of any additional service

More information

Patient Questionnaire Auto-Collision

Patient Questionnaire Auto-Collision Patient Questionnaire Auto-Collision Patient Name: (First) (Middle) (Last) (Suffix) Today's Date: / / Birth Date: / / Age: SSN: Gender: (circle) F M Height: ft in Weight: lbs (circle one) Right handed

More information

ADVICE FOR PATIENTS WITH NECK PAIN

ADVICE FOR PATIENTS WITH NECK PAIN ADVICE FOR PATIENTS WITH NECK PAIN Patient Information Leaflet Physiotherapy Department (Information sheet code SHOT/SHOA) A SMOKING FREE ENVIRONMENT WAHT-TH-007-1 - Version 1.2 Dear Patient This advice

More information

Bankart Repair For Shoulder Instability Rehabilitation Guidelines

Bankart Repair For Shoulder Instability Rehabilitation Guidelines Bankart Repair For Shoulder Instability Rehabilitation Guidelines Phase I: The first week after surgery. Goals:!! 1. Control pain and swelling! 2. Protect the repair! 3. Begin early shoulder motion Activities:

More information

Q. Officer, I am placing a copy of your department report face down in front of you.

Q. Officer, I am placing a copy of your department report face down in front of you. GateWay Community College Phoenix, AZ Q/A Dictation (20 word Count) Q. Officer, I am placing a copy of your department report face down in front of you. Please feel free to use that document at any time

More information

Knee Arthroscopy Exercise Programme

Knee Arthroscopy Exercise Programme Chester Knee Clinic & Cartilage Repair Centre Nuffield Health, The Grosvenor Hospital Chester Wrexham Road Chester CH4 7QP Hospital Telephone: 01244 680 444 CKC Website: www.kneeclinic.info Email: office@kneeclinic.info

More information

WHAT TO DO AFTER A BIKE SHARE CRASH

WHAT TO DO AFTER A BIKE SHARE CRASH WHAT TO DO AFTER A BIKE SHARE CRASH By Daniel Flanzig, Esq. and James B. Reed, Esq. On Memorial Day New York City launched it s long awaited Bike Share Program. With an initial start of 6000 bikes, the

More information

Road Traffic Accidents Do s and Don ts & the Legal Process

Road Traffic Accidents Do s and Don ts & the Legal Process Legal Discussion on Tipp FM with Orlagh Wafer 22 nd January 2013 Road Traffic Accidents Do s and Don ts & the Legal Process Introduction As the temperatures are dropping and the roads are becoming more

More information

MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE

MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE Please answer all questions completely: 1. Your name and address: 2. Phone Number: 3. In your own words, please describe the accident: 4. Where did

More information

1.8 Organisation details. Name

1.8 Organisation details. Name Claim form Please read our booklet Guide to making a Motor Insurers Bureau claim before you fill in this form. The booklet gives information about the MIB and how we deal with claims. l Please complete

More information

Cycle Accident Compensation Guide. Winston Solicitors LLP

Cycle Accident Compensation Guide. Winston Solicitors LLP Cycle Accident Compensation Guide Winston Solicitors LLP Compensation guide If you are unlucky enough to be involved in pedal cycle accident, it is important that you receive advice on your rights, responsibilities

More information

Cast removal what to expect #3 Patient Information Leaflet

Cast removal what to expect #3 Patient Information Leaflet Cast removal what to expect #3 Patient Information Leaflet SM466 Now your cast is off, self help is the key! Follow the advice given to you by your doctor and the staff in the clinic. Your skin will be

More information

Name, Today's Date Accident Date _

Name, Today's Date Accident Date _ Name, Today's Date Accident Date Please answer the following questions as accurately and honestly as possible. This fonn is very important and will aid your doctor in providing you the best ~ as well as

More information

Upper Arm. Shoulder Blades R L B R L B WHICH SIDE IS MORE PAINFUL? (CERVICAL PAIN SIDE) RIGHT LEFT EQUAL NOT APPLICABLE (N/A) CERVICAL.

Upper Arm. Shoulder Blades R L B R L B WHICH SIDE IS MORE PAINFUL? (CERVICAL PAIN SIDE) RIGHT LEFT EQUAL NOT APPLICABLE (N/A) CERVICAL. 1 NECK PAIN Patient Name In order to properly assess your condition, we must understand how much your NECK/ARM problems has affected your ability to manage everyday activities. For each item below, please

More information

Fatality Claim Form. South Australia Compulsory Third Party (CTP)

Fatality Claim Form. South Australia Compulsory Third Party (CTP) South Australia Compulsory Third Party (CTP) Fatality Claim Form This form is to be completed by any person who is claiming compensation as a result of a person s death in a motor vehicle accident (please

More information

Automotive Collision Injury Form

Automotive Collision Injury Form Automotive Collision Injury Form Billing Information Patient name: Date of Injury: Time of injury: AM PM City and street where crash occurred: What is the estimated damage to your vehicle? $ Do you have

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

Bus Passenger Accident Guide. Winston Solicitors LLP

Bus Passenger Accident Guide. Winston Solicitors LLP Bus Passenger Accident Guide Winston Solicitors LLP Compensation guide If you are unlucky enough to be injured in an incident whilst travelling on a bus or other public transport vehicle, it is important

More information

Rehabilitation after shoulder dislocation

Rehabilitation after shoulder dislocation Physiotherapy Department Rehabilitation after shoulder dislocation Information for patients This information leaflet gives you advice on rehabilitation after your shoulder dislocation. It is not a substitute

More information

Whiplash Associated Disorder (WAD)

Whiplash Associated Disorder (WAD) Information for patients Whiplash Associated Disorder (WAD) Physiotherapy Department Tel: 01473 703312 DPS ref: 05731-14(RP) Issue 3: December 2014 Review date: November 2017 The Ipswich Hospital NHS Trust,

More information

Minibus Policy. The Trust has several minibuses available ranging from seven (7) to seventeen (17) seats, all with standard seat belt restraints.

Minibus Policy. The Trust has several minibuses available ranging from seven (7) to seventeen (17) seats, all with standard seat belt restraints. Minibus Policy The Trust has several minibuses available ranging from seven (7) to seventeen (17) seats, all with standard seat belt restraints. They are used to: 1. Extend our curriculum into the local

More information

DANISH ROAD TRAFFIC ACCIDENT INVESTIGATION BOARD

DANISH ROAD TRAFFIC ACCIDENT INVESTIGATION BOARD DANISH ROAD TRAFFIC ACCIDENT INVESTIGATION BOARD Anne Eriksson, Traffic safety engineer, Anna Louise Feerup, Psychologist, Danish Road Directorate This paper presents The Danish Road Traffic Accident Investigation

More information

Wrist Fracture. Please stick addressograph here

Wrist Fracture. Please stick addressograph here ORTHOPAEDIC UNIT: 01-293 8687 /01-293 6602 UPMC BEACON CENTRE FOR ORTHOPAEDICS: 01-2937575 PHYSIOTHERAPY DEPARTMENT: 01-2936692 GUIDELINES FOR PATIENTS FOLLOWING WRIST FRACTURE Please stick addressograph

More information

Exercise and advice after breast cancer surgery

Exercise and advice after breast cancer surgery Exercise and advice after breast cancer surgery Irving Building Physiotherapy All Rights Reserved 2015. Document for issue as handout. Role of the physiotherapist Exercises for the first week following

More information

YOUR ACCIDENT GUIDE CAR INSURANCE IMPORTANT PUT THIS IN YOUR GLOVE BOX. Claims Helpline 0800 300 252 PLEASE WRITE YOUR POLICY NUMBER HERE

YOUR ACCIDENT GUIDE CAR INSURANCE IMPORTANT PUT THIS IN YOUR GLOVE BOX. Claims Helpline 0800 300 252 PLEASE WRITE YOUR POLICY NUMBER HERE CAR INSURANCE YOUR ACCIDENT GUIDE IMPORTANT PUT THIS IN YOUR GLOVE BOX PLEASE WRITE YOUR POLICY NUMBER HERE Claims Helpline 0800 300 252 DON T FORGET TO PUT THIS NUMBER IN YOUR MOBILE PHONE LEFT STRANDED?

More information

LEGAL ETHICS IN CTP LITIGATION. Hon John Doyle AC, QC Peter Day, Jeffcott Chambers Brenton James, Hunt & Hunt

LEGAL ETHICS IN CTP LITIGATION. Hon John Doyle AC, QC Peter Day, Jeffcott Chambers Brenton James, Hunt & Hunt LEGAL ETHICS IN CTP LITIGATION Hon John Doyle AC, QC Peter Day, Jeffcott Chambers Brenton James, Hunt & Hunt JD (John Doe) was involved in a motor vehicle accident. He was a passenger travelling with his

More information

NTSU Fleet Vehicle Driving

NTSU Fleet Vehicle Driving Severity Date: Updated1/12/12 What Is Being Assessed: Describe the hazard & how it can The Driver Collision with other or pedestrians Assessed By: Colin Hutchinson NTSU Fleet Vehicle Driving and other

More information

Motor Vehicle Collision Form

Motor Vehicle Collision Form Patients Name: Date: / / 1) Please choose the date of the MVC: / / 2) Please the time of the MVC: : am / pm 3) Please enter the number of vehicles involved in the MVC: 1 2 3 4 5 6 7 8 9 4) In dollars,

More information

OFFICE OF THE STATE CORONER FINDINGS OF INQUEST

OFFICE OF THE STATE CORONER FINDINGS OF INQUEST OFFICE OF THE STATE CORONER FINDINGS OF INQUEST CITATION: TITLE OF COURT: JURISDICTION: Inquest into the death of Lydia Spencer Coroners Court CAIRNS FILE NO(s): 2014/1631 DELIVERED ON: 3 November 2014

More information

PREVIEW PLEASE DO NOT COPY THIS DOCUMENT THANK YOU

PREVIEW PLEASE DO NOT COPY THIS DOCUMENT THANK YOU Form: Personal injury automobile accident case checklist PERSONAL INJURY AUTOMOBILE ACCIDENT CASE CHECKLIST Did you witness the accident? Yes No When? Where? How far were you from the accident? Describe

More information

Victims of Crime the help and advice that s available

Victims of Crime the help and advice that s available Details about Victim Support Your local Victim Support Scheme is: Victims of Crime the help and advice that s available You can also contact the Victim Supportline on: 0845 30 30 900 Or, if you prefer,

More information

Motor Vehicle. Claim Report

Motor Vehicle. Claim Report Motor Vehicle Claim Report Please retain this page for your information IMPORTANT INFORMATION ABOUT YOUR CLAIM This form must be completed and signed by the person who was driving your vehicle, or the

More information

1.8 Organisation details Name. Address. 1.9 Is the organisation VAT registered?

1.8 Organisation details Name. Address. 1.9 Is the organisation VAT registered? Claim form You must read our booklet Motor Insurers' Bureau, Making a claim before you fill in this form. The booklet gives information about the MIB and how we deal with claims. Please use black ink and

More information

Personal Injury Claims Involving Motorcyclists. Richard Cole Barrister, Civitas Law. www.civitaslaw.com. Introduction

Personal Injury Claims Involving Motorcyclists. Richard Cole Barrister, Civitas Law. www.civitaslaw.com. Introduction Personal Injury Claims Involving Motorcyclists Richard Cole Barrister, Civitas Law www.civitaslaw.com Introduction Case law emanating from the appellate courts concerning road traffic accidents often involve

More information

PERSONAL INJURY QUESTIONNAIRE. NAME: Date of Accident

PERSONAL INJURY QUESTIONNAIRE. NAME: Date of Accident PERSONAL INJURY QUESTIONNAIRE NAME: Date of Accident Where did accident happen? Describe the accident in your own words: What was your position in the car? Driver: if Driver were your hands on the steering

More information

How To Fill Out A Claim Form For A Car Accident In The Uk

How To Fill Out A Claim Form For A Car Accident In The Uk Motor Vehicle Claim Report Please retain this page for your information IMPORTANT INFORMATION ABOUT YOUR CLAIM This form must be completed and signed by the person who was driving your vehicle, or the

More information

Keeping You on the Move. Policy Wording

Keeping You on the Move. Policy Wording Keeping You on the Move Policy Wording Contents Keeping You on The Move...3 page 2 Important Information Keeping You on The Move Helpline 0845 873 7832 Customer Services Department 0845 683 0741 Please

More information

LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B

LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B 1 Patient Name In order to properly assess your condition, we must understand how much your BACK/LEG (SCIATIC) PAIN has affected your ability to manage everyday activities. For each item below, please

More information

Motor Vehicle Operations Program

Motor Vehicle Operations Program Motor Vehicle Operations Program July 31, 2008 Introduction The Texas Transportation Institute (TTI) is committed to providing a safe and healthful environment for its employees and visitors. All activities

More information

MEDICAL REPORT ACC/675/413 SOLICITOR'S REF. Smith and Smith Solicitors INSTRUCTIONS FROM. Janet Jones CLIENT'S NAME

MEDICAL REPORT ACC/675/413 SOLICITOR'S REF. Smith and Smith Solicitors INSTRUCTIONS FROM. Janet Jones CLIENT'S NAME MEDICAL REPORT SOLICITOR'S REF INSTRUCTIONS FROM CLIENT'S NAME ADDRESS ACC/675/413 Smith and Smith Solicitors Janet Jones 18 Cross Drive, Cheadle Hulme, Cheadle DOB 09 August 1955 DATE OF ACCIDENT 01 September

More information

Model Fleet Safety Program Short

Model Fleet Safety Program Short TM Model Fleet Safety Program Short CORPORATE HEADQUARTERS 518 EAST BROAD STREET COLUMBUS, OHIO 43215 614.464.5000 STATEAUTO.COM TM Disclaimer: The information contained in this publication was obtained

More information

Information for patients Exercise and advice after breast cancer surgery

Information for patients Exercise and advice after breast cancer surgery Information for patients Exercise and advice after breast cancer surgery Physiotherapy Salford Royal NHS Foundation Trust Stott Lane, Salford, M6 8HD Telephone: 0161 206 5328 Page 1 of 5 Role of the physiotherapist

More information

MISTAKES COMMONLY MADE BY POTENTIAL CLAIMANTS

MISTAKES COMMONLY MADE BY POTENTIAL CLAIMANTS MADE BY POTENTIAL At Sinnamon Lawyers, we understand the complex legal and insurance issues that underpin personal injury and damages claims. If you have been injured in a motor vehicle accident or workplace

More information

Wrist Fracture Advice

Wrist Fracture Advice NHS Forth Valley Wrist Fracture Advice NB (A fracture is the same as a break) Patient Information Leaflet Introduction The plaster is not removed until the broken bone is healed. Phalanges Metacarpal Bones

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

Accident Claim Number - You Have Been Laid, Now What?

Accident Claim Number - You Have Been Laid, Now What? Personal Injury Information First Name: / / Address: City/Town: Last Name: Phone: State: Zip Code: Your Auto Ins. Co Phone: Address: Accident Claim #: Agent s Name: Driver/Other Vehicle: Ins. Co: Policy

More information

Report of a Complaint Handling Review in relation to Police Scotland

Report of a Complaint Handling Review in relation to Police Scotland Case reference: PIRC/00308/13 March 2014 Report of a Complaint Handling Review in relation to Police Scotland under section 35(1) of the Police Public Order and Criminal Justice (Scotland) Act 2006 Summary

More information

The Physiotherapy Pilot. 1.1 Purpose of the pilot

The Physiotherapy Pilot. 1.1 Purpose of the pilot The Physiotherapy Pilot 1.1 Purpose of the pilot The purpose of the physiotherapy pilot was to see if there were business benefits of fast tracking Network Rail employees who sustained injuries whilst

More information

Premier patient information. Whiplash. Whiplash Exercises

Premier patient information. Whiplash. Whiplash Exercises Premier patient information Whiplash Whiplash Exercises Keep moving! It may be painful but you ll get back to normal much quicker. Moving forward (in fact - moving in any direction!) Movement is the key

More information

How To Tell Someone You Were Injured In A Car Accident

How To Tell Someone You Were Injured In A Car Accident Personal Injury Questionnaire Answer each question fully and accurately. Success in this case depends on mutual confidence and complete cooperation between you (as the client) and the attorney. It is imperative

More information

LYDIA MAPHOKA LEKHEHLE

LYDIA MAPHOKA LEKHEHLE IN THE HIGH COURT OF SOUTH AFRICA (ORANGE FREE STATE PROVINCIAL DIVISION) Case No. : 6765/08 In the appeal between:- LYDIA MAPHOKA LEKHEHLE Appellant and ROAD ACCIDENT FUND Respondent HEARD ON: 10 MAY

More information

RESPONSE TO THE DEPARTMENT FOR TRANSPORT CONSULTATION PAPER CHANGES TO THE TREATMENT OF PENALTIES FOR CARELESS DRIVING AND OTHER MOTORING OFFENCES

RESPONSE TO THE DEPARTMENT FOR TRANSPORT CONSULTATION PAPER CHANGES TO THE TREATMENT OF PENALTIES FOR CARELESS DRIVING AND OTHER MOTORING OFFENCES RESPONSE TO THE DEPARTMENT FOR TRANSPORT CONSULTATION PAPER CHANGES TO THE TREATMENT OF PENALTIES FOR CARELESS DRIVING AND OTHER MOTORING OFFENCES 4 SEPTEMBER 2012 Introduction This is the response of

More information

History Questionnaire

History Questionnaire History Questionnaire Today s Date Physician Patient Information Patient s Name Is this your legal name? Street Address Mr. Miss. Marital Status (circle one) Mrs. Ms. Single Mar Div Sep Wid If not, what

More information

THIS IS A REPORT TO THE COURT BASED UPON THE HISTORY OF THE INJURIES SUSTAINED BY THE CLAIMANT, HIS/HER TREATMENT, CONDITION AND PROGNOSIS.

THIS IS A REPORT TO THE COURT BASED UPON THE HISTORY OF THE INJURIES SUSTAINED BY THE CLAIMANT, HIS/HER TREATMENT, CONDITION AND PROGNOSIS. MEDICAL REPORT THIS IS A REPORT TO THE COURT BASED UPON THE HISTORY OF THE INJURIES SUSTAINED BY THE CLAIMANT, HIS/HER TREATMENT, CONDITION AND PROGNOSIS. NAME: ADDRESS: PTSD Whiplash Birmingham DOB: Age

More information

<< INSERT COMPANY NAME

<< INSERT COMPANY NAME > SLIIP-TRIIP-FALL & STRAIIN IINJURY TRAIINIING > Fall Prevention Slips, trips, and falls constitute the majority of general industry accidents. They cause 15% of

More information

THE CHARTERED INSTITUTE OF LEGAL EXECUTIVES UNIT 9 PREPARATIONS FOR PERSONAL INJURY TRIALS * SUPPORTING MATERIALS

THE CHARTERED INSTITUTE OF LEGAL EXECUTIVES UNIT 9 PREPARATIONS FOR PERSONAL INJURY TRIALS * SUPPORTING MATERIALS 16 January 2015 Level 4 PREPARATIONS FOR PERSONAL INJURY TRIALS Subject Code L4-9 THE CHARTERED INSTITUTE OF LEGAL EXECUTIVES UNIT 9 PREPARATIONS FOR PERSONAL INJURY TRIALS * SUPPORTING MATERIALS Information

More information

Policy: Driving Issued By: SHE Team Effective Date: March 2015 Review Date: March 2016 Version: 1. Driving Policy

Policy: Driving Issued By: SHE Team Effective Date: March 2015 Review Date: March 2016 Version: 1. Driving Policy Policy: Driving Effective Date: March 2015 Review Date: March 2016 Driving Policy 1. POLICY STATEMENT 2. SCOPE 3. RESPONSIBILITY 4. DEFINITIONS 5. PROCEDURE 5.1 Alternatives to Driving 5.2 Authorisation

More information

CARPAL TUNNEL SYNDROME A PATIENT GUIDE TO THE NURSE-LED CARPAL TUNNEL SERVICE

CARPAL TUNNEL SYNDROME A PATIENT GUIDE TO THE NURSE-LED CARPAL TUNNEL SERVICE CARPAL TUNNEL SYNDROME A PATIENT GUIDE TO THE NURSE-LED CARPAL TUNNEL SERVICE Information Leaflet Your Health. Our Priority. Page 2 of 6 What is carpal tunnel syndrome? It is entrapment of a nerve at the

More information

WHAT SHOULD I DO IF I HAVE AN AUTO ACCIDENT? 1. If I have an auto accident, do I have to stop? 2. What should I do if someone is injured?

WHAT SHOULD I DO IF I HAVE AN AUTO ACCIDENT? 1. If I have an auto accident, do I have to stop? 2. What should I do if someone is injured? WHAT SHOULD I DO IF I HAVE AN AUTO ACCIDENT? 1. If I have an auto accident, do I have to stop? 2. What should I do if someone is injured? 3. How can I get help? 4. What information should I gather at the

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

Injuries from lifting, loading, pulling or pushing can happen to anyone in any industry. It is important to be aware of the risks in your workplace.

Injuries from lifting, loading, pulling or pushing can happen to anyone in any industry. It is important to be aware of the risks in your workplace. Workplace safety: lifting One of the biggest concerns in the workplace is lifting and loading. When you lift something, the load on your spine increases and your spine can only bear so much before it is

More information

Helping you to make a speedy recovery after a groin hernia repair

Helping you to make a speedy recovery after a groin hernia repair Helping you to make a speedy recovery after a groin hernia repair Groin hernia repair Contents Who this leaflet is for 2 What to expect after the operation 3 Things that will help you recover more quickly

More information

Do you sit at a desk all day? Does your 9 to 5 leave no time for structured exercise..?

Do you sit at a desk all day? Does your 9 to 5 leave no time for structured exercise..? Do you sit at a desk all day? Does your 9 to 5 leave no time for structured exercise..? Staying healthy at work is easier than you might think: Try building the following desk based exercises into your

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

City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:

City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip: Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: Work

More information

Ms Forename Surname. Injured Party: Ms Forename Surname. Medico-legal Expert: Dr Asef Zafar GP. Instructing Party: Instructing Party

Ms Forename Surname. Injured Party: Ms Forename Surname. Medico-legal Expert: Dr Asef Zafar GP. Instructing Party: Instructing Party Medico-legal Report of Dr Asef Zafar Ms Forename Surname On behalf of Instructing Party (ref: 547355) 1 TITLE OF ACTION: In the case of: Forename Surname v. Generic Insurance (Defendant: Name Surname)

More information

DECISION NUMBER 749 / 94 SUMMARY

DECISION NUMBER 749 / 94 SUMMARY DECISION NUMBER 749 / 94 SUMMARY The worker suffered a whiplash injury in a compensable motor vehicle accident in May 1991. The worker appealed a decision of the Hearings Officer denying entitlement when

More information

The State Government recognises. areas, and regulates bicycle

The State Government recognises. areas, and regulates bicycle cycling & THE LAW rules introduction for roads The State Government recognises The cycling South Australian as a legitimate Road Traffic form of Act including transport the Australian and an increasingly

More information

Journal. A workbook designed to organize and survey your incident & injury throughout the road to recovery. tywilsonlaw.

Journal. A workbook designed to organize and survey your incident & injury throughout the road to recovery. tywilsonlaw. YOUR INJURY Journal A workbook designed to organize and survey your incident & injury throughout the road to recovery SLIP/FALL CAR ACCIDENT WORKERS COMP TY WILSON LAW tywilsonlaw.com 866-937-5454 YOUR

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

WHAT TO DO IF YOU HAVE AN AUTOMOBILE ACCIDENT

WHAT TO DO IF YOU HAVE AN AUTOMOBILE ACCIDENT WHAT TO DO IF YOU HAVE AN AUTOMOBILE ACCIDENT INTRODUCTION Automobile accidents are a regrettable part of modern life. Whether you drive in a large city or a small town, sooner or later, you can expect

More information

Report of a Complaint Handling Review in relation to Northern Constabulary

Report of a Complaint Handling Review in relation to Northern Constabulary Case reference: PCCS/00658/PF- NC June 2010 Report of a Complaint Handling Review in relation to Northern Constabulary under section 35(1) of the Police Public Order and Criminal Justice (Scotland) Act

More information

Commentary Drive Assessment

Commentary Drive Assessment Commentary Drive Assessment Time start: Time finish: Candidate s Name: Candidate s Email: Date of Assessment: Location: Candidate s Supervisor: Supervisors Contact Number: Supervisors Email: Assessor s

More information

PARTICULARS OF CLAIM - ROAD TRAFFIC ACCIDENT (Claim by Driver)

PARTICULARS OF CLAIM - ROAD TRAFFIC ACCIDENT (Claim by Driver) Client Ref. No. PARTICULARS OF CLAIM - ROAD TRAFFIC ACCIDENT (Claim by Driver) 2001 Please use the Notes for Guidance when completing this form. Note 1. IN THE Claim No. Note 2. Between Claimant Note 3.

More information