Excellum Legal Solicitors
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info@excellumlegal.com
0161 7888 000
Mon - Fri: 9:00 am - 06.00pm / Closed on Weekends
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Home
About Us
Our Services
UK Immigration
Business Visa
Personal Visa
Study Visa
Family Visa
Personal Injury
Medical Negligence
Commercial Litigation
Debt Recovery
Other Services
Administrative Removal
Immigration Appeals
Detention and Deportaion
Judicial Review
Asylum Application
Lease Drafting Services
Landlord & Tenant Disputes
Wills and Probate
Claim Form
info@excellumlegal.com
0161 7888 000
Home
About Us
Our Services
UK Immigration
Business Visa
Personal Visa
Study Visa
Family Visa
Personal Injury
Medical Negligence
Commercial Litigation
Debt Recovery
Other Services
Administrative Removal
Immigration Appeals
Detention and Deportaion
Judicial Review
Asylum Application
Lease Drafting Services
Landlord & Tenant Disputes
Wills and Probate
Fees Page
Contact Us
Claim Form
CLAIM FORM
FILL YOUR DETAILS
Claim Form
Step
1
of
13
- General Details
7%
Email
What type of claim do you want
Medical Negligence
OIC Injury / Losses
PLOL Questionnaire
RTA Claim
MR/MRS/MISS:
Firstname(s)
Surname(s)
Address
Street Address
City
ZIP / Postal Code
Landline No
Mobile No
Email
Date of Birth
Month
Day
Year
National Insurance No
Marital Status
Single
Married
Divorced
Widowed
Employer Status
Employed
Self-employed
Retired
Occupation
Start Date
MM slash DD slash YYYY
Current Employer(s)
Clock or Work No
Address
Street Address
City
ZIP / Postal Code
Landline No
E-mail
No of Sites
Existing Insurance
Union Membership
Details of Wife/Dependents
Name & Address of your GP
Are you in receipt of any state benefits or state compensation – if so, what
Benefit Office Address
Do you have Legal Expenses Insurance?
Yes
No
How did you hear about Excellum Legal Solicitors?
I confirm that the following information is accurate to the best of my knowledge and I authorise Excellum Legal Solicitors to pursue my claim for damages for personal injury and loss.
I confirm that the following information is accurate to the best of my knowledge and I authorise Zen Law Solicitors to pursue my claim for damages for personal injury and loss.
(A) What DATE did the negligence happen and where? What time?
(B) Who was your treating doctor/surgeon at the time? Please provide full details
(C) Please describe in detail what happened, including why you needed treatment, what treatment was provided, what injury or symptoms were caused to you, what further treatment you had
(D) Were there any witnesses to the incident? If so, please provide names, addresses and contact numbers
(E) Was there any involvement by the Medical Association?
Yes
No
(F) What procedures were explained prior to commencing the treatment? Did you sign a Consent Form?
(G) Were the risks explained to you before the treatment? Who explained the risks? What date?
(H) Who was responsible for the supervision and who was present or involved in the treatment? What was the nature and extent of that supervision?
(I) Are you aware of any previous incidents at the GP/Hospital of a similar nature?
(J) Did you complain to the medical practitioner and/or supervisor and relevant governing body? Have they admitted liability (blame) for the incident?
(K) Have any systems or procedures changed as a result of the incident?
(L) What, in your opinion, were the errors or omissions in your treatment?
(M) Please briefly describe what injuries you suffered as a result of the negligence
Do you have any photographs of your injuries?
Yes
No
Please Upload photographs
Max. file size: 128 MB.
(O) Were you unconscious as a result of the incident? If so, for how long?
(P) When did your injuries become apparent or what date did you learn of the negligence/errors?
(Q) Who explained that there had been a failure in your treatment, if any? If this was more than 3 years ago, when did you realise your current medical condition was linked to your previous medical treatment?
(R) If you received private treatment, please give details of the treatment and address of the medical facility
(S) What is the current status of any injury, what pain it is causing, what treatment have you had since and is there any long-term/permanent damage?
(T) If you are continuing to receive treatment, where are you receiving this and what treatment? What dates have you attended for your treatment since the incident?
(U) What diagnosis has been provided by your treating doctor?
(V) If you are yet to make a full recovery, please provide details of your symptoms
(W) Have you ever suffered from similar conditions/symptoms prior to the negligent treatment?
(X) Were you absent from work as a result of the accident? If so, please provide pay slips (or accounts if self-employed) for 13 weeks prior to the accident and confirm between what dates you were absent
(Y) Did you work overtime prior to the incident? If so, what hours and for what periods
(Z) Have you received any State Benefits as a result of the accident e.g. Statutory Sick Pay, Invalidity Benefit?
Please describe your injuries in further detail as much as possible and how they have affected your work, social and sporting activities. Provide details of medication expenses if available.
Case Reference
TO:
Employer Name
Employer Address
Name in Full (including former name if changed)
Date of Birth
MM slash DD slash YYYY
National Insurance No
Address & Postcode (including former addresses if changed)
CONTACT DETAILS:
Home Tel
Work Tel
Mobile Tel
E-mail
Disclouser
CONSENT FOR RELEASE OF OCCUPATIONAL HEALTH/PERSONNEL RECORDS & ALL RELATED DOCUMENTATION
I consent to the disclosure of my Occupational Health/Personnel Records (and all related documentation) to
Signature
Full Name
Please Enter Full Name
OIC INJURY / LOSSES QUESTIONNAIRE
The information requested in this RTA Injury/Losses Questionnaire will help us to assess the strength of your claim and also to advise you about how the case should be funded. Please provide as much information as possible.
Case Reference
CLIENT INJURIES
1. Soft Tissue
Neck
Back
Shoulder
2. Rib/Chest/Torso
Fracture
Sprain or Strain
Cuts or Scarring
Bruising or Abrasions
3. Face / Cheekbones / Jaw / Nose
Fracture
Sprain or Strain
Cuts or Scarring
Bruising or Abrasions
4. Damage to Teeth
5. Forearm/Wrist/Hand/Finger(s)
Fracture
Sprain or Strain
Cuts or Scarring
Bruising or Abrasions
6. Head / Senses
Headaches
Cuts or Scarring
Bruising or Abrasions
Senses Affected
7. Hips / Pelvis / Genitals
Fracture
prain or Strain
Cuts or Scarring
Bruising or Abrasions
8. Leg / Knee / Ankle / Foot / Toe
Fracture
Sprain or Strain
Cuts or Scarring
Bruising or Abrasions
9. Shock / Anxiety / Other Psychological Conditions
Shock
Anxiety
Other
10. Multiple Injuries
Property
Repairs/Total Loss
Repairs/Total Loss
Storage/Recovery
Storage/Recovery
Temporary (Hire) Vehicle
Temporary (Hire) Vehicle
Loss of Use
Loss of Use
Travel Expenses
Travel Expenses
Excess
Excess
Diminution
Diminution
Other Items
Other Items
If Other Items/Additional Info:
Injury-Related
Treatment Costs
Treatment Costs
Prescription/Med Costs (£10 default)
Prescription / Med Costs (£10 default)
Loss of Earnings
Loss of Earnings
Care Costs
Care Costs
Travel Costs (£10 default)
Travel Costs (£10 default)
Other Costs
Other Costs
If Other Costs/Additional Info
GP Surgery Name
Address
What was the date of your first visit?
MM slash DD slash YYYY
Did you go to Accident & Emergency?
Yes
No
Which hospital did you visit?
On what date did you attend?
MM slash DD slash YYYY
Have you attended any other hospitals for treatment?
Yes
No
Hospital
Ref
Admission Date
MM slash DD slash YYYY
Consultant
Department
Did you visit any other treatment providers (e.g. a physiotherapist)?
Yes
No
Please provide details of treatment provider
Are you due to receive any further treatment?
Yes
No
Please provide details of treatment provider:
ADDITIONAL INFORMATION
Please tell us anything else that you think we should know – eg are your soft tissue injuries EXCEPTIONAL? Meaning the degree of pain, suffering or loss of amenity (impact on day-to-day life) on you was severe.
I confirm
I confirm that the following information is accurate to the best of my knowledge and I authorise Excellum Legal Solicitors to pursue my claim for damages for personal injury and loss.
Signed
Date
MM slash DD slash YYYY
Case Reference
Information Requested
The information requested in this Questionnaire will help us to assess the strength of your claim and also to advise you about how the case should be funded. Please provide as much information as possible. If you have any questions about the Questionnaire please contact the Personal Injury department on
0161 7888 000
.
Section 1 – Your Details
MR/MRS/MISS Name(s)
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
MR/MRS/MISS
First Name
Surname
Address
Street Address
ZIP / Postal Code
Landline No
Mobile No
E-mail
Date of Birth
MM slash DD slash YYYY
National Insurance No
Marital Status
Single
Married
Divorced
Widowed
Employer Status
Employed
Self-employed
Retired
Occupation
Start Date
MM slash DD slash YYYY
Current Employer(s)
Clock or Work No
Address
Street Address
ZIP / Postal Code
Landline No
E-mail
No of Sites
Existing Insurance
Union Membership
Details of Wife/Dependents
Are you in receipt of any state benefits or state compensation – if so, what
Benefit Office Address
Do you have Legal Expenses Insurance?
Yes
No
(Please household insurance, credit card insurance etc. to see if you have legal costs insurance which may cover your legal costs)
How did you hear about Excellum Legal Solicitors?
Signed
(A) Please advise of (1) the DATE OF ACCIDENT (2) describe the location of the accident and (3) whether it was reported to anyone
(B) Please describe in detail the circumstances of the accident. What were you doing immediately before the accident happened and what happened immediately afterwards. In particular, why do you hold the occupier or public authority responsible for the accident?
Please provide a sketch if relevant
Accepted file types: jpg, png, pdf, Max. file size: 10 MB.
(C) Please describe what treatment you had following the accident, including first aid and whether there was any hospital attendance. If there was hospital attendance, the name of the hospital and whether you are still attending for treatment
(D) Do you have photographs of the defect/hazard?
Yes
No
Please provide photographs
Accepted file types: jpg, png, , Max. file size: 10 MB.
(E) Do you wear glasses or contact lenses?
Yes
No
(F) What type of footwear were you wearing at the time of the accident?
(G) Were there any witness to the accident?
Yes
No
If so, please provide details including names, addresses and telephone numbers
(H) Has there been any official investigation into the circumstances surrounding the accident?
(I) Has there been any admission of liability (blame) by the other party?
(J) Has anything been changed as a result of the accident? If so, please state what
(K) Have there been any previous accidents similar to yours? If yes, please provide details
(L) Were you absent from work as a result of the accident? If so, please provide pay slips (or accounts if self-employed) for 13 weeks prior to the accident and confirm between what dates you were absent
(M) Did you work overtime prior to the accident? If so, what hours and for what periods
(N) Have you received any State Benefits as a result of the accident e.g. Statutory Sick Pay, Invalidity Benefit?
(O) Please describe your injuries in as much detail as possible and how they have affected your work, social and sporting activities. Provide details of medication expenses and copy photographs if available
(P) Please provide us with any other relevant comments and information if you think it would assist your case
Claim Type
Personal Injury
Loss of Earnings
Damaged Property/Clothing
Vehicle Damage
Travel Expenses
Care
Hire Charges
Medical Expenses
Private Therapy
Loss of Use
Storage/Recovery
Name
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Mr/Mrs/Miss/Other
First Name(s)
Surname
Parents Name
(if client under 18)
Address
Street Address
ZIP / Postal Code
Tel No
Mobile No
Date of Birth
MM slash DD slash YYYY
N.I No (or reason why none)
Occupation
Date of Accident
MM slash DD slash YYYY
Time of Accident
Hours
:
Minutes
AM
PM
AM/PM
Place of Accident
Road Conditions
Wet/Dry/Snow/Icy/Foreign substance
Weather
No of Occupants in your vehicle (if applicable)
Description of Accident:
Sketch (label streets/buildings/ vehicles where possible)
Your Vehicle Details (if applicable)
Make & Model
Vehicle Reg No
Insurer
Type of Cover
Policy No
Witness Details (if known)
Name
Contact Number
Address
Details of Third Parties
Name
Address
Street Address
ZIP / Postal Code
Tel No
Insurer
Address
Street Address
ZIP / Postal Code
Vehicle Reg No
Make & Model
Police Involvement
Called?
Yes
No
Attended?
Yes
No
Attending Officer name
Reference Number
CCTV Held?
Hospital details (if attended)
Hospital Name
Address
Date Attended
MM slash DD slash YYYY
GP Details
GP Surgery Name
Address
Date(s) Attended
MM slash DD slash YYYY
Hospital 2 details (if attended)
Hospital Name
Address
Date Attended
MM slash DD slash YYYY
Treatment Provider details eg Physiotherapy
Name
Address
Date Attended
MM slash DD slash YYYY
Treatment Provider 2 details
Name
Address
Date Attended
MM slash DD slash YYYY
Employer Details
Name
Address
Dates Absent
MM slash DD slash YYYY
School/College Details
Name
Address
Date Absent
MM slash DD slash YYYY
Witness Details (if known)
Name
Contact Number
Address
More details description of Injuries
Caree Details (family member of professional)
Name
Contact Number
Address
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