Claim Today Solicitors

Tel: 08000 93 93 92

Please contact Davy Bal Solicitors today on this number

Accident at Public Place

Public Liability Claim

FE/CLINO/MATTERNO

Please complete this form and sign and date it. Do not delay returning the form if you do not have an answer to each question.

YOUR DETAILS

EMPLOYMENT DETAILS

ACCIDENT DETAILS

Date of the Accident		*
Time of the Accident		(HH) (MM)
Exactly where did the accident happen		*
LAND/PROPERTY OWNER’S DETAILS
Name		*
Address		*
Please confirm why you feel that the property owner is at fault for the accident and what steps you feel they could have taken to avoid the accident occurring.
Did you report the accident?		Yes No *
(If yes, who to and what was their position?)
Was any record made in relation to the accident		Yes No *
(If yes, what type or record,e.g recorded in the accident book)
Do you have any photographs of where the accident happended?		Yes No
(If so, please provide copies)
Note:- If you do not have photos please obtains some as early as possible and forward them to us

WITNESSESES/EVIDENCE

Were there any witnesses to the accident? If yes, please provide contact details below:		Yes No *
Witness 1:
Name
Address


Telephone Number
Witness 2:
Name
Address


Telephone Number
If there are any other witnesses, please insert their details in the right hand column.
Name
Address


Telephone Number