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Personal Injury Case Review

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Name
Enter your date of birth.
Enter Your Home Address
Enter your Job Title, name of your workplace, and work address
Email
Enter area code eg. 246 then the remaining digits
Enter date the accident occurred
Enter the address where the accident occurred
Were you travelling as:
Please select the one that applies
Please enter the details of the motor vehicle in which you were travelling, including the Name of the owner, their address, the diver of the vehicle and their address (if different from the owner), the license plate number of the vehicle and the name of the insurance company with which the vehicle is insured. Please enter ALL the details that you have available.
Please enter the details of the other motor vehicle(s) involved in the accident including the Name of the owner, their address, the diver of the vehicle and their address (if different from the owner), the license plate number of the vehicle and the name of the insurance company with which the vehicle is insured. Please enter ALL the details that you have available. If there is more than one vehicle involved, please enter details for each vehicle in a separate paragraph.
Please provide details about the accident, eg how the accident occurred, who was driving, the direction in which the vehicles were travelling, any steps that you took to avoid the accident, names of any persons who witnessed the accident, etc,
Please enter details about your injury, including areas where you are having pain, whether you have been given sick leave, and whether you require assistance at home, along with any other relevant details about your injury.
Please provide details including name and address of any doctors that you have seen in relation to the accident, whether you were hospitalized and if so for how long, and whether you were prescribed medication, etc. Obtaining medical treatment after an accident is a crucial step in pursuing a personal injury claim as a medical report written by a doctor is required to support your claim. It is important that you see a doctor as soon as possible after sustaining an injury.
If known, please enter the name(s) of the Police Officer(s) who attended the scene and the Police Station where they are attached.
Please enter any additional information you would like to provide.
Agreement and Consent
By submitting this form, you agree to the Altus Chambers Terms of Service, Privacy Policy, and Legal Services Agreement Terms. You also give consent to Altus Chambers to contact you in relation to the information you have provided. Submitting this form does not mean that you have retained our services. We will review your information and follow up for further details to confirm that there is no conflict of interest and that we can represent you. If you do not agree these terms, do not submit the form.
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