Personal Injury Form INJURIESPlease describe the injuries you have suffered as a result of the accident in as much detail as possible.Date of accident MM slash DD slash YYYY Time of Accident Hours : Minutes AM PM AM/PM Place of accident Were you wearing a seat belt? Yes No Which side of the car were you at? Was police or ambulance called? Who was the driver? Vehicle registration Number Your National Insurance Number When did those injuries first become apparent? Did you go to the hospital/gp. Please give detailsAre your injuries continuing? Yes No Please describe ongoing symptoms. On what date were you fully recovered? MM slash DD slash YYYY Did you lose consciousness at all during the accident? Yes No If yes, how long for? Have you had any injuries or disabilities in the past which may have had an effect on your present condition? Yes No If yes, please give details. Please provide photographs of your injuries if available?Max. file size: 128 MB.TREATMENTHave you been prescribed or taking any medication for your injuries? Yes No If yes please give details. Has treatment been recommended/provided by a medical professional? E.g. physio, counselling Yes No If yes please give details. EFFECTS ON LIFESTYLE AND FINANCIAL LOSSLoss of Earnings – Self EmployedAre you self-employed and suffered loss of business? Yes No Before any insurer will consider a claim for loss of earnings, you must, where appropriate produce the information and evidence detailed below. Please note that if you were not able to work but you were able to postpone work to a later date, or if you have obtained work to replace that which you lost, you may not have suffered any lost business profit. If, however, you have lost income, or if you have sustained increased business costs by paying an employee or contractor to work additional hours due to your accident-related absence or incapacity, you may have a claim to pursue. Please provide copies of the following documents by way of evidence to support your loss: 1. Your Tax Returns and Tax Calculations by way of reply from the Tax Office for the last three years. If you do not have your Tax Return and related Calculations, please complete and return the enclosed Tax Office mandate in order that we can apply to them directly. 2. Your profit and loss accounts for the last three years. 3. Your work schedule for the 6 months prior to the accident to date. 4. Bank statements for your business account for the 6 months prior to the accident to date. 5. If you are claiming for increased wage roll costs, please provide copies of your payroll accounts to show that the increased cost starting during your period of absence and returning to its pre-accident level upon your return to normal duties. Please let us have the names and addresses of relevant employees/contractors. 6. Copies of any cancelled contracts, letters to/from customers whose work you lost, etc. 7. Any other documents that you consider would support your claim for lost business profit. If you employ an account to maintain your income records, you may well feel it more appropriate and easier for your accountant to provide all of the above information. Please note that you would be responsible for this fee in the first instance however we would include it as part of your claim against the other party and try and recover the cost on your behalf. We cannot guarantee that we would be successful in recovering this cost. Should you pay your accountant for providing the required information and documentation please ensure you provide us with a copy of the paid invoice. In the event that you wish to provide us with the required information yourself but do not have you Tax Returns readily available, we enclose a mandate authorising CS Legal Consultants to access information and documentation direct from the Inland Revenue relating to your earnings and tax liability. Can you please sign and return the mandate. Attach all documents hereMax. file size: 128 MB.Medical and Care ExpensesHave you incurred any medical expenses Yes No Hospital charges for emergency treatment. Prescription charges and the cost of non-prescription items, e.g. pain killers. Surgical supports, bandages, tub grip, etc. Treatment provided by physiotherapists, or other practitioners on a private basis. Please describe Please provide copy documentation / receipts to support your claim.Max. file size: 128 MB.Have your injuries interfered with your normal domestic activities such as washing and dressing or housework? Yes No If yes please give details. Have you been receiving any help/care to carry out domestic activities? Whether that is by a professional or family member/friend. Yes No If yes please give details. Please note, if a loved one, family member or friend is providing care due to your injuries. Please keep a diary confirming the period of care, the hours per day and the actual tasks the carer is conducting on your behalf. Please also confirm the name and address of the carer. The claim will be calculated at £9.24 per hour. We must advise however, that the hourly rate of £9.24 is claimable for professional care and there will be considerable deductions made by the third party’s insurers as the care and assistance you are receiving is not being provided by a professional carer. The figure of £9.24 will be utilised to start the negotiation process. Are there any leisure activities that your injuries have prevented you from undertaking? Yes No If yes please give details. Travel ExpensesHave you incurred any travelling expenses e.g. attending for treatment, GP or hospital visits Yes No If yes please give details. Please provide copy documentation / receipts / details of mileage to support your claim. I.e. taxi receipts, fuel receiptsMax. file size: 128 MB.Other Expenses or Items of Specific LossWas any of your clothing or were any personal possessions damaged in the accident? Yes No If yes please give details. Have you incurred any other financial losses? Yes No If yes please give details. Please provide copy documentation / receipts to support your claim.Max. file size: 128 MB.Please sign Date MM slash DD slash YYYY This site is using SEO Baclinks plugin created by Cocktail Family