Slip and Trip Claim Form

Please describe in your own words how the accident happened
Name*
Address*
Postcode*
Daytime Tel. no.*
Email*
Date and Time of Accident*
Place of Accident
Address where accident happened*

If the accident was a slipping accident, please advise the following:

Do you know what you slipped on?	Yes No If yes, please state
Do you know how long the item/liquid had been there?	Yes No If yes, please state
Do you know how the item/liquid got there?	Yes No If yes, please state
Were there any warning signs regarding the hazard the item/liquid was causing?	Yes No
Were there any members of staff etc, advising of the hazard?	Yes No
Had any attempts been made to clean the item/liquid?	Yes No If yes, please state
Did any members of staff/public assist you following the accident? Do you know who they were?	Yes No If yes, please state
Was an entry of the accident made in the accident record book?	Yes No
Do you know who owns the property where you slipped?	Yes No If yes, please state

Tripping / Highway Claims

NB. It is always a good idea to take photographs of any defect before they are repaired. It may assist your claim.

If the accident occurred by tripping in or over a defect in the highway:

Names and addresses of any witnesses
How was the defect created? (i.e. raised manhole, worn kerb etc)
How long, wide and how deep was the defect?
Do you have any idea how long the defect had been present?	Yes No If yes, please state
Have you seen the defect before?	Yes No
Do you think the defect was dangerous to pedestrians?	Yes No
The area where the accident happened is:	Rural Shopping Area Residential Village / Small Town
How often do you use the stretch of highway where the accident occurred?
What was the weather like at the time of accident?
If the accident did not occur in daytime, was there any artificial lighting i.e. streetlamps? If so please provide the number on the nearest streetlamp for information purposes
Was the defect over which you tripped/fell fenced or displaying any hazard warning signs?	Yes No
Were there any contractors working in the area i.e. British Gas, Water Board, Cable and Wireless?	Yes No If yes, please state
Could the accident have been caused by their negligence?	Yes No

Losses

As a result of the accident you may have suffered other losses such as travelling expenses, e.g. taxis or bus fares to hospital or work. Below are a set of standard questions of which some may be relevant to your circumstances. If you have suffered any loss of a type not listed please give details in the space provided at the end of the standard questions.

Please give details of travel expenses suffered as a direct result of the accident and forward copy receipts if available.

Please give details of items of clothing or other items damaged as a result of the accident and forward copy of receipts for the items or their replacement if possible.

If you have suffered any other losses please advise below.

Loss of income

You may have suffered loss of income as a result of the accident, if so please answer the following questions.

Have you suffered any losses of income as a result of accident. If yes please give details	Yes No
Number of days absent from work (state if continuing)
Name and address of your employer (please state if self-employed)
If employed please advise job description
Gross Salary	Weekly Monthly
Net Salary	Weekly Monthly

Please provide evidence of your income in the form of wage slips to cover a period of 13 weeks prior to the accident (or letter from employer)

Please do not delay submitting this form if you are unable to provide wage slips at this stage.

Do you have any objections to us writing to your employers to obtain details / confirmation of your loss?	Yes No

If self-employed please advise:

Job description
Estimate of loss to date

In an order to substantiate your loss you may be required to provide details of your accounts. Please state whether you will be able to provide copy accounts or proof of loss by other means, i.e. accountants letter.

Name and addresses of book-keeper/accountant:

	I agree that the above information is true and correct to the best of my knowledge and belief at this time.

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