Name
Email
Phone number
Address
Date of birth
Town/Place of birth
National insurance number
Occupation at time of incident
Incident date and time
Incident address/location
Name of person who injured you (If you know it)
Incident details (What Happened?)
Was the incident reported the police
When was the Incident reported to the police
Crime reference number and officers details
Who reported the incident to the police
Did you make a police statement
Was the offender prosecuted
Describe your Injuries
Did you have any treatment such as physiotherapy for your Injuries
Are you still receiving treatment
Did you attend hospital for your injuries (If Yes give the date and hospital address below)
Please give your GP Details
If you attended your GP what date did you first attend
If you needed dental treatment please give details including treatment dates and address of the dentist
Have you claimed for criminal injuries before
please give details of any criminal convictions that you have (if any)
