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