Please fill out this report in as much detail as you can to support your claim.

Slip and Fall Form

Name

First Last

Email

Phone

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date of birth

National Insurance number

Date of accident

Time of accident

:

Location of accident

Description of accident (as much detail as possible)

Details of injuries

Are the symptoms/treatment ongoing?

Hospitals/GP attended and dates of attendances

Full names and addresses of any accompanying persons

Witness details – are they likely to be of assistance?

Photographs of injuries and/or defect/location of defect (ideally require photos of defect with ruler and approach to defect)

Max. file size: 256 MB.

Description/Size of defect

Direction and pace when encountered defect

How often would you walk in that direction?

Who do you think is to blame & why?

Are you aware of any other accidents at the accident location?

What type of footwear were you wearing?

Was a hand rail available?

Had you consumed any alcohol?

What were the ground/weather conditions e.g. icy, wet or greasy

Were you carrying anything?

Were there any signs warning/advising that the ground may be hazardous?

Have you suffered any loss of earnings?

Any other expenses incurred? e.g. travel to medical appointments, private physiotherapy, damaged items etc.?

Do you have legal expenses insurance?

Yes

No

I don't know