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

 

Storage 

 

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. 

Have a question or need some help? Call us today on 020 3553 2429

Expert legal advice you can rely on,
get in touch today:

Please let us know you are not a robot