Can I claim? How much will I get? Free Consultation

Occupational Disease: Can I Claim?

To see if you have a claim please call us on 0800 7344 999 and one of our experienced staff will be only too pleased to talk to you. Alternatively please complete our simple questionnaire below and we will call you back at a time convenient to you.

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Accident Summary

Are you or have you ever been
a member of a trade union? Yes No

Date you became aware
of your illness: Date: Approx.

What do you believe caused your illness:

What are your current medical symptoms:

Have you received Medical Treatment? Yes No

Where were you treated:

Contact details

Contact Information

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Your information is protected by our Privacy Policy.

Title Mr Mrs Miss Other

First Name:

Last Name:

How to Contact You? Phone Email

Email: We will never sell or disclose your email address to anyone.

Phone:

Mobile:

When should we contact you: If by phone.