HW Solicitors -RTA Questionnaire
Email address *
Full name
Your answer
Address
Your answer
Date of birth
MM
/
DD
/
YYYY
Telephone number
Your answer
National Insurance Number
Your answer
Occupation
Your answer
Date of accident
MM
/
DD
/
YYYY
Time of accident
Time
:
Location of accident
Your answer
Weather conditions
Your answer
Road conditions
Your answer
How did the accident happen?
Your answer
Details of injuries
Your answer
Did you attend hospital?
What date was/is hospital attendance?
MM
/
DD
/
YYYY
Did you attend your GP?
What date was/is GP attendance?
MM
/
DD
/
YYYY
Are you currently undergoing treatment?
Have you had any time off work?
Were you the driver or a passenger?
Were you wearing a seatbelt?
Where any other people in your vehicle?
Your answer
Registration, make and model of your vehicle.
Your answer
Details of damage to your vehicle.
Your answer
Is your insurance company repairing your vehicle?
Registration, make and model of the other vehicle.
Your answer
Describe the damage to the other vehicle.
Your answer
Please provide all information provided by the other driver. ( name, address, telephone number, insurance company, policy number etc).
Your answer
Details of any witnesses
Your answer
Did the police attend?
Do you have any legal expense insurance, for example provided with your home contents insurance?
Have you previously made a claim for injury? If yes, please advise date of accident(s) and type of injury
Your answer
Is there anything else you think we should know?
Your answer
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