Accident Claims Form

If you have been injured in a car accident, and would like to pursue a claim, please complete each field of this claim form, giving us as much detail as possible. We aim to respond to your enquiry within 1 working day.

Client details


Client vehicle details


Client/driver insurance details 


GP details


Hospital details


Heads of claim * (tick all that apply)




Hire provider details




Employment details


Accident details


Passenger details

Passenger 1


Passenger 2

Passenger 3

Passenger 4

Police Attendance


Description of accident


Third party/driver at fault details


Client - previous accidents


Where did you hear about us?

* We need this information 
You must ensure the information provided on this claim form is accurate. Failure to provide accurate information may delay the settlement of your claim, adversely affect your claim or discredit you as a witness. © QualitySolicitors Mirza 2014. All rights reserved. 

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