Free Assessment

How did you become injured?

Car Accident Accident at work Motorcycle Accident Hazardous Substance Tripping Accident Slipping Accident Defective Product Holiday Accident Industrial Deafness Running Down Medical Negligence Asbestos Dust Other

Who was mainly to blame?

Another driver Own driver Employer Fellow employee Subcontractor Owner of premises Local council Seller/manufacturer Tour operator Hospital GP Other

Why do you blame the above?*

What are your main injuries?

Neck injuries Back injuries Arm injuries Shoulder injuries Wrist injuries Hand injuries Leg injuries Knee injuries Ankle injuries Foot injuries Facial injuries Internal injuries Deafness Injuries to eyesight Psychiatric injuries Cuts and bruises Lung Injuries Other

If you injuries are asbestos-related, is the relevant employer who caused your exposure still in existence?

Yes No

Have you made a full recovery, or do you have continuing symptoms?

Full recovery Continuing severe symptoms Continuing mild symptoms

What is the date of your injury (or the date of diagnosis)?

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Do you have any witnesses?

Yes No

If you have witnesses, are they likely to support your claim?

Yes No Not sure Not applicable

Has there been any kind of official investigation?

Yes No Not sure

Has there been any admission of blame by the other party?

Yes No Not sure

Have there been any previous similar incidents, accidents, complaints, or previous similar instances of exposure?

Yes No Not sure Not applicable

Have you been off work, or 'out of action' as a result of your injuries?

Yes No

If so, for how long?

Up to a week Up to a fortnight Up to a month Up to 6 months Over 6 months Permanently off work Unemployed Retired No time off work

Do you wish to claim for loss of earnings?

Yes No

If you live in the UK, then in which region?

West Midlands East Midlands Wales South West North West London South East North East Scotland

Alternatively, if you live outside the UK, then where?

USA Australia New Zealand Canada South Africa Other English speaking territory Continental Europe Asia Africa

Would you prefer a telephone call at home or at work?

At home At work

Which day of the week would you prefer to be contacted?

Monday Tuesday Wednesday Thursday Friday Saturday Any day As soon as possible

When is the most convenient time to speak?

Early morning Late morning Lunchtime Early afternoon Late afternoon Early evening Saturday morning Any time

Please give a convenient telephone number where we can reach you*

Please state your name*

Please give a convenient e-mail address where we can reach you

Please state any further relevant facts which we ought to know about. Is your opponent denying your claim? If so, why?

Kindly state where you heard about Kremers:

yell.com Scoot Talking Pages Law Society SPG Delia Venables Other solicitors Citizens Advice Bureau Personal Recommendation Yellow Pages Infoseek Northern Light Lycos Open Directory Ask Jeeves Fast Lawyers for Birmingham Lycos Alta Vista Yahoo! MSN Hotbot AOL UK Plus Excite Anzwers Google The Law Store Other search engine Other referral source

Finally, please state if you found us by using a keywords search, or alternatively if you arrived via successive hyperlinks using your mouse.

Keywords search Hyperlinks  

Please enter the text in the image:

Please click the 'submit' button to send us the details, which will be treated in the strictest confidence, and not released to any third parties.

We will then contact you as close as possible to the time you specify. Any personal injury advice given regarding your potential claim will be on a free, no obligations basis, and does not constitute the acceptance of formal legal instructions.

Thank you for completing this questionnaire. Your interest is much appreciated and we look forward to hearing from you.