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FREE Claim Check v3
Where were you injured?
*
While Working
On the Road
On the Water
Public Place
In Surgery / Misdiagnosed
Death/Injury of Relative
Did you suffer financial loss as a result of this injury?
*
Yes
No
Where did the accident happen?
*
NSW
ACT
VIC
QLD
NT
SA
WA
TAS
Did the accident happen BEFORE December 2017?
Yes
No
When did the accident occur?
*
Less than 6 months ago
More than 6 months ago
More than 3 years ago
How did your injury happen?
*
One off Accident
Work Conditions
Multiple Incidents
Aggravation of a Previous Injury
What was the source of their fatality/Injury?
Incident at Work
Road Accident
Medical Error
Accident in a Public Place
Other
What injuries did you sustain?
Broken Bone(s)
Fracture(s)
Disc Bulge
Bruising
Burns or Scarring
Concussion
Trauma and/or Shock
Anxiety and/or Depression
Loss of hearing
Death of passenger(s)
Other
What injuries did you sustain?
Broken Bone(s)
Fracture(s)
Disc Bulge
Bruising
Burns or Scarring
Concussion
Trauma and/or Shock
Anxiety and/or Depression
Loss of hearing
Death of a Relative
Other
What injuries did you sustain?
Broken Bone(s)
Fracture(s)
Disc Bulge
Burns or Scarring
Bruising
Concussion
Trauma and/or Shock
Anxiety and/or Depression
Loss of hearing
Mesothelioma, Silicosis or Asthma
Other
What injuries did you sustain?
Physical
Concussion
Internal Organs
Trauma and/or Shock
Anxiety and/or Depression
Loss of hearing
Complications in Pregnancy
Death of Relative
Other
What vehicle were you in?
*
Pedestrian
Car or Truck
Motorcycle or Scooter
Train
Bus
Tractor, Forklift or Buggy
Bicycle or Skateboard
Other
What vehicle were you in?
*
I was swimming
Boat
Jet Ski
Ferry
Kayak or Canoe
Other
What vehicle(s) were involved in the accident?
*
Pedestrian
Car or Truck
Motorcycle or Scooter
Ferry
Train
Bus
Tractor, Forklift or Buggy
Bicycle or Skateboard
Other
What vehicle(s) were involved in the accident?
Swimmer
Boat
Jet Ski
Ferry
Kayak or Canoe
Other
Did an ambulance take you to hospital?
No there was no ambulance at the scene
Yes I was taken to hospital
Yes but I wasn't taken to hospital
Did Police Attend the Scene?
No
No but there is an Event number
Yes there is a Police Report
I am not sure
Who do you believe is responsible for the accident?
It was the other side's fault
It was my fault
It was a bit of both
The road was unsafe (tree falls, damaged, unrestrained animal)
Do you require surgery for any of these injuries?
Yes
No
Full Name
*
Phone
*
Would you like to provide further details?
*
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