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HW Solicitors -RTA Questionnaire
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* Indicates required question
Email
*
Your email
Full name
Your answer
Address
Your answer
Post code
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
:
AM
PM
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?
Yes
No
I am going
Clear selection
Which hospital did you attend?
Your answer
What date was/is hospital attendance?
MM
/
DD
/
YYYY
Did you attend your GP?
Yes
No
I am going
Clear selection
What date was/is GP attendance?
MM
/
DD
/
YYYY
Are you currently undergoing treatment?
Yes
No
Clear selection
Have you had any time off work?
Yes
No
Clear selection
Are you still off work?
Yes
No
Clear selection
If back at work, how many days in total have you had off work?
Your answer
At the time of the accident were you the
Driver
Front seat passenger
Rear seat passenger
Cyclist
Pedestrian
Other:
Clear selection
Were you wearing a seatbelt?
Yes
No
Clear selection
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?
Yes
No
Maybe
Clear selection
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?
Yes
No
Maybe
Clear selection
What reference do you have?
Your answer
Do you have any legal expense insurance, for example provided with your home contents insurance?
Yes
No
Maybe
Clear selection
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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