Personal Injury Claim Form

Make an enquiry with with Scott Rees & Co

Please fill out this form to start your claim.

Title
Name*
First Last
Recommendation Code (if any)
Email
Phone Number (preferred contact)*
What is the best time to call you?
Where did you hear about us?
Do you require a translator?
If yes, for what language?
Do you wish to add more details about your accident? i.e injury suffered, insurance details, passenger/witness details
Claimant Details continued
Tel (other)
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Occupation
Date of Birth
MM slash DD slash YYYY
National Insurance Number
Do you need a call back?
What number would you like to be contacted on?
Accident Details
What type of accident claim are you looking to make?
What type of injury has been suffered?
Date of accident or injury (DD/MM/YYYY)
MM slash DD slash YYYY
Where did the accident that caused the injury take place?
Time of accident
Was the accident reported?
What best describes you?
Does your car need inspecting?
Were you wearing a seat belt when the accident took place?
Did the police attend the scene of the accident?
If yes, what was the name of the officer?
What police station was the officer from?
What was their police reference number?
If you would like to describe more about the accident, please do so here:
Injury Details
What type of injury was suffered?
Did you attend the hospital or see a GP as a result of the accident?
If yes, what date did you attend the hospital of GP (DD/MM/YYYY)
MM slash DD slash YYYY
Which hospital did you attend?
Details of loss of earnings
Will you/have you had any loss of earnings as a result of your accident?
What period of time were you forced to take off because of your injury?
Are you a taxi driver?
If yes, do you keep records? (do not send them)
What is your approximate weekly net loss (£)
Name of employer
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Insurance Details
What is the name of your insurance company?
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Policy Number
First Last
Type of insurance cover
What is your excess?
Do you have a legal expenses policy?
Passengers (road traffic accidents only)
Did you have any or were you travelling alongside any other passengers?
Passenger 1 details
Title
Name
First Last
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Phone number
Email
Type of injury suffered
National Insurance Number
Best time to call back
Passenger 2 details
Title
Name
First Last
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Phone number
Email
Type of injury suffered
National Insurance Number
Best time to call back
Passenger 3 details
Title
Name
First Last
Title
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Phone number
Email
Type of injury suffered
National Insurance Number
Best time to call back
Passenger 4 details
Title
Name
First Last
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Phone number
Email
Type of injury suffered
National Insurance Number
Best time to call back
Witnesses
Were there any witnesses to the accident?
Witness 1 details
Title
Name
First Last
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Phone number
Email
Witness 2 details
Title
Name
First Last
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Phone number
Email
Witness 3 details
Title
Name
First Last
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Phone number
Email
Witness 4 details
Title
Name
First Last
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Phone number
Email
Third Party Details
Title
Name
First Last
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Tel Home
Tel Work
Mobile number
Email Address
Insurance company name
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Insurance policy reference number
Insurance company phone number
Make of vehicle
Model of vehicle
Registration Number
Does the Third Party own the vehicle?
If no, then what is the full name for the owner of the vehicle?
First Last
What is the address for the owner of the vehicle?
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
What is the phone number for the owner of the vehicle?
Declaration
Name
First Last
Date (DD/MM/YYYY)
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Awards, Accreditations & Associations

Scott Rees & Co has an outstanding record for providing excellent client care and customer experiences. Here are some awards and accreditations to show that we meet the high standards of the industry.

You can read more about our awards and accreditations here.

Committed to you every step of the way

Scott Rees & Co are one of the best rated law firms on Trustpilot in the UK.
We value customer feedback and are always striving to improve our service levels.

Personal Injury Claim Form

Claimant Details continued

Accident Details

Injury Details

Details of loss of earnings

Insurance Details

Passengers (road traffic accidents only)

Passenger 1 details

Passenger 2 details

Passenger 3 details

Passenger 4 details

Witnesses

Witness 1 details

Witness 2 details

Witness 3 details

Witness 4 details

Third Party Details

Declaration

Awards, Accreditations & Associations

Committed to you every step of the way