Morrish & Co Solicitors

Require fields are indicated.

Full Name:(required)

Date of Birth:(required)

Address:(required)

Daytime Telephone:

Evening Telephone:

Mobile:

Email Address:(required)

Date of Accident:(required)
(Date of onset of symptoms in disease cases)

If an accident, was the accident:

Work Related On The Road Trip or Slip Other

Tell us a little about your accident / occupational disease:

Who was responsible or at fault?
Name:

Address:

What happened?(please give as much information as possible)

What injuries did you suffer?

Which Hospital did you attened?

How many times did you visit the Hospital?

Who is your current GP?
Name:

Address:

How many times did you visit your GP?

Have you been absent from work as a result of your injuries?
Yes No

If yes, for how long were you absent from work?:

Who was/is your Employer?
Name:

Address:

What was/is your job title?

How much do you/did you earn per week/month after tax?
per week per month

What is your National Insurance number?

How would you like us to contact you?
Email Phone at Home Phone at Work By Letter By Mobile

What time(s) would be best to call?
9am - 12pm 12pm - 2pm 2pm - 5pm 5pm - 8pm

Please note that submission of this form will only allow one of our solicitors to contact you for full instructions and to advise upon the merits of your claim. No retainer is established and no instructions are accepted by Morrish & Co until we have confirmed acceptance of instructions in writing..

IMPORTANT

A claim for personal injuries must be brought within 3 years of the accident date, except in certain limited circumstances e.g. claims by children. If you are aware that the time limit in your case is soon to expire then please do not use this form, but instead telephone on 0113 245 0733 to discuss your claim. Delay almost always proves fatal to a claim.

Morrish & Co solicitors can accept no responsibility for the expiry of time limits due to the delay in the submission of instructions, or failure of email delivery. If you have not heard from us within 2 working days of submission of this form, please telephone us on 0113 245 0733.

I have read and understand the information set out above (required)

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