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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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