Personal Injury Form for Passenger

Step 1 of 5

Claimant

Full Name*

Address*

Date of Birth*

Nation Insurance Number*

Occupation*

Phone*

Email*

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Step 2 of 5

Defendant (Business or Private )

If Business then Company name and Driver name, if private then Driver full name*

Address*

Vehicle Registration*

Make*

Model*

Email*

Phone*

Insurance*

Policy Number*

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Step 3 of 5

Medical

Soft Tissue*
YesNo

Whiplash*
YesNo

Bone Injury*
YesNo

Other*
YesNo

Injury description*

Work time Off*

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Still off work*

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How Many days*

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GP Attendance*

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When (when dates appear)

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Attendance

Hospital Attendance*

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When (when dates appear)

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Rehabilitation*

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Step 4 of 5

Accident Detail

How Many occupants?*

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Person 1*

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Person 1*

Person 2*

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Person 1*

Person 2*

Person 3*

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Person 1*

Person 2*

Person 3*

Person 4*

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Person 1*

Person 2*

Person 3*

Person 4*

Person 5*

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Person 1*

Person 2*

Person 3*

Person 4*

Person 5*

Person 6*

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Can we contact them?*

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If no Why?*

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wearing a seat belt?*

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If no Why?*

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Claiming against own driver?*

Driver - Full Name*

Driver - Address*

Vehicle Owner - Full Name*

Vehicle Owner - Address*

Vehicle Registration*

Make*

Model*

Insurance*

Policy Number*

Accident Date*

Accident Time*

Location*

Weather Condition *

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Please add details*

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Road Condition*

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Please add details*

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Accident circumstances description*

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Please add details*

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Accident Facts*

Police

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Reference Number*

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Step 5 of 5

Accident Involving

Accidents involving a bus or a coach*

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Driver Name*

Driver ID*

Driver Description*

Description of vehicle, including route number and direction of travel, colour and markings of vehicle*

Approximate number of passengers on the bus/coach*

Is evidence of travel available?*

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Witness

Any Witness *

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Witness - Full Name*

Witness - Address*

Witness - Phone*

Witness - Email*

Can We Contact*

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Please Mention Why*

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Liability

Why does the claimant believe that the defendant was responsible for the incident?*

Other*

Signature*

I am the claimant. I believe that the facts stated in this claim form are true. I understand that proceedings for contempt of court may be brought against anyone who makes, or causes to be made, a false statement in a document verified by a statement of truth without an honest belief in its truth.

I have retained a signed copy of this form including the statement of truth

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If No Why*

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Contact us

Our Recent Live Google Reviews

Great service. Highly recommend!

Gerta Bicaku

I have used the service before and this was the reason I used again because the service Privilege Solicitors has provided was impeccable. I also have recommended others to use their services. They have acted professionally in dealing with my matters and kept me updated with my claim. The members of the staff were very polite and courteous. It is hard to find a company these days who are prompt and top of their games.

abdal Chowdhury
i m satisfied with services and good quality work Thank privilege solicitors

adnan kabri

Most reliable, reasonable and efficient solicitors in the area.. I have been using some big names solicitors in the area in past and they use to charge hefty amounts of fees and after that they never use to have time to listen to us with our queries.. Mr. Imran at Privilege Solicitors replied me straight away with any query I had.. I didn't had to go through with stress.. they know what are they doing and they are best in it.. thank you team Privilege for looking after your clients and doing so hard work

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