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First Name:
Surname:

Home Telephone Number:        

Mobile Telephone Number:        



Did your accident happen in the last three years?        Yes       No

Did you receive medical attention for your injuries?       Yes       No

Was the accident your fault?                                   Yes       No

Where were you injured?

Foot         Ankle         Knee         Leg
Hand Wrist Elbow Arm
Hips Back Neck Head





Accident type:                                            

Please provide a brief description of your accident (optional)

 

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Easy2Claim is regulated by the Ministry of Justice in respect of regulated claims management activities; its registration is recorded on the website www.claimsregulation.gov.uk

 

Our authorisation number is CRM19727