REF:- ........................

ACCIDENT ASSESSMENT (UKonly)

NAME............................................................................

ADDRESS...................................................................................

...............................................................................................

POSTCODE.............................

TELEPHONE NUMBERS

Home............................Business..................................Mobile.....................................................

NATIONAL INSURANCE No...................................

DATE OF BIRTH.................................

OCCUPATION...........................................................................................................

DATE, TIME OF ACCIDENT.....................................................

PLACE OF ACCIDENT...........................................................

TYPE OF ACCIDENT...........................................................

Additional Information

STATEMENT

Signed...................................................................Date........................................................

Accident Details

Who was responsible for the accident? Name and address etc Name / Address etc.
Slip/Trip were Council informed? How were they informed; Previous accident in this location.
Could the person who was responsible have avoided the accident, and how could they have avoided this?
What were you doing at the time of the accident? Were there any safety signs displayed?
Were you required to wear any protective clothing?
Were you required to comply with any safety regulations?
Did any person in Authority attend the accident? Name/Address
Has the accident been reported to the Health and Safety Executive?
Name & address of any other person involved in the accident.
Has your accident been recorded in the Accident Record Book?
Name, Address & Policy No. of the insurers of the person you hold responsible.
If your injury occurred in the work- place, does your employer have a manual of working practices.
Have you any photographs of the accident scene?

EMPLOYMENT DETAILS

Name, address and Telephone Number of Employer.
Have you returned to work and on what date?
Loss of earnings:- Gross earning per week:- Net earning per week:-

DAMAGE TO PROPERTY

Loss or Damages (Bus/Taxi fares etc.) (Please provide receipts)
Damage to clothing/property (Please provide estimated value of replacement)

WITNESS DETAILS

Name Address Tel No.
Name Address Tel No.

INJURIES

Did you hit your head?	YES/NO
Have you had Headaches? (How often and how severe)	YES/NO
Have you fainted or felt dizzy at all?	YES/NO
Have you had any sickness or nausea?	YES/NO
Any sensation of pins and needles?	YES/NO
Have you had double vision or trouble focusing?	YES/NO
Were you unconscious or concussed?	YES/NO
Can you remember all events prior to/at the time and after the accident?	YES/NO
Do you have any cuts? (Any stitching or scarring)	YES/NO
Do you have bruises? (description)	YES/NO
Serious injuries Extent of injuries	YES/NO
Have you suffered from shock at all?	YES/NO
Do you intend to seek private medical treatment? If so, costs involved.	YES/NO
Details of previous injuries if any.	YES/NO

MEDICAL ATTENDANCE

Did you attend hospital?	YES/NO
Hospital attended
Tel No
Doctor (if known)
Were you detained?	YES/NO
Have you seen your GP?	YES/NO
GP name & address
Tel No.

Declaration of Consent

I ...................................................... of .................................................................................. ................................................ hereby authorise Stemma Legal Services to appoint a nominated solicitor to act on my behalf to recover any compensation and damages that I am entitled to arising out of my accident which occurred on ..........................................................

I declare that the information given is true to the best of my knowledge. I authorise and request any cheques in settlement of any part of my claim for damages or loss to be drawn in favour of my nominated solicitor. Further, the solicitor has my authority to pay any disbursement as are deemed necessary.

Signed...........................................................Dated.................................................................

Hospital and GP record Authorisation

I ...................................................... of .................................................................................... .........................................................., hereby give my consent for ........................................... to have access to my GP and Hospital notes and nursing records and/or medical records kept by my employers medical department.

My General Practitioner is:-

Tel.No...............................

The Hospital attended was

Tel No................................

Were x-rays taken on your attendance at the hospital Yes/No

My Date of birth is ..............................

My National Insurance No. Is ...............................

I certify that no legal action is contemplated against my Practitioner and/or the Health Authority in respect of any medical treatment received.

Signed............................................................Dated...............................................................

Thank you for submitting the form, we will be contacting you shortly