Yes I Want to Make a Claim

Please complete the following form as fully as possible before pressing the submit button. The more information you give us the easier it will be to assess your claim.

We will respond to your form by close of business the next working day after receipt.
If you have not received a response within this timescale please contact us by telephone on 0113 274 0100

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Postal address

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Date of birth

National Insurance Number

Current employer

Date of accident

Accident details

Injury details

Any other losses

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