Report a Claim new form

Main Claim Form

Step 1 of 15

Driver / Passenger details

Title

Forename:(Required)

Middle name:

Last name:(Required)

Email(Required)

Phone(Required)

Occupation(Required)

Ni Number(Required)

Vehicle Details:

Car Registration(Required)

Make & Model:(Required)

Insurance Company(Required)

Policy Number

Vehicle Owner Detail: (If Other)

Title

Forename:

Middle name:

Last name:

Address:

Post Code

DOB

NI Number

Occupation

Contact Number

Only fill in if applicable otherwise please skip

Tick all applicable(Required)

Personal Injury

Vehicle Damage

Car Storage

Car Hire

Vehicle Recovery

Loss of Earning

Other

Instruct Engineer:

Select an option below

Yes

Engineer:

(If you don’t have this info please skip)

Hire company:

(If you don’t have this info please skip)

Date started:

(If you don’t have this info please skip)

Whose fault was the accident?(Required)

Select an option below

My Fault

Other Driver (Third Party)

50/50

Not sure

Where did the accident take place?(Required)

Select an option below

England/Wales

Scotland

Northern Ireland

Injury Details

Injury Sustained(Required)

Select an option below

Yes

Did you attend Hospital:(Required)

Select an option below

Yes

Time of Work:(Required)

Select an option below

Yes

Appointment date / Date attended hospital:

DD slash MM slash YYYY

GP Details:(Required)

Hospital Details:

Did you attend GP:(Required)

Select an option below

Yes

Accident Information

Third Party Details:

Car Registration(Required)

Make & Model:(Required)

Colour:(Required)

Name:(Required)

Co Name:

Phone No:(Required)

Address

Insurance Co:

Policy Number:

Other Vehicle Involved:

Car Registration

Make & Model:

Colour:

Name:

Phone No:

Insurance Co:

Policy Number

Accident Detail:

Date(Required)

DD slash MM slash YYYY

Time(Required)

Hours

Minutes

Weather:(Required)

Location:(Required)

Please upload an image from google maps

Drop files here or

Accepted file types: png, jpg, jpeg, pdf, Max. file size: 12 MB, Max. files: 2.

Number of occupants:(Required)

Name of occupant 1(Required)

Prefix First Last

Name of occupant 2(Required)

Prefix First Last

Name of occupant 3(Required)

Prefix First Last

Name of occupant 4(Required)

Prefix First Last

Name of occupant 5(Required)

Prefix First Last

Name of occupant 6(Required)

Prefix First Last

Police Called:(Required)

Select an option below

Yes

Police Station:(Required)

Cad No:(Required)

Ref No:(Required)

Officer Name:(Required)

Contact No:(Required)

Are there any witnesses:(Required)

Select an option below

Yes

How many witnesses?(Required)

Select an option below

Witness 1

Name:(Required)

Phone No:(Required)

Mobile:

Address:(Required)

Post Code:(Required)

Any other details:

Witness 2

Name:(Required)

Phone No:(Required)

Mobile:

Address:(Required)

Post Code:(Required)

Any other details:

Description & Sketch of Accident

Descritpion:

Sketch

Drop files here or

Accepted file types: jpg, png, pdf, jpeg, Max. file size: 128 MB.

CONDITIONAL FEE AGREEMENT

This Agreement is a legally binding contract between you and your solicitor. The Conditions are part of the Agreement. Before you sign or give any instructions, please read everything carefully.

Agreement Date:

DD slash MM slash YYYY

Between:(Required)

Name

And : Lincoln Lewis Solicitors

What IS covered by the Agreement

All of the work we do on your claim for damages against any other party subsequently found liable for your incident, which occurred on or about 19th November 2019, including taking initial instructions and any pre-action applications.
Any appeal by your opponent.
Court action to enforce your compensation award if you win but your opponent does not pay.
Any appeal you make against an interim order during the proceedings.

What IS NOT covered by this Agreement

Any counterclaim against you.
Any appeal you make against a final judgement or order.

The Agreement

Our Basic Charges for the legal work we do are based on the rates we charge, as outlined in our terms of business per hour for each hour we are engaged on your case. Letters and telephone calls are charged out on a time recorded basis at 1/10th of the hourly rate.

To these are added our success fee, which can be as high as 100% of our basic charges but will not exceed 25% of any damages you receive (excluding any future losses and any sum repayable to the Compensation Recovery Unit (CRU) of the Department for Work and Pensions).

We review our charges annually each January and will increase them in line with those set out in the Guide to Summary Assessment published by the Senior Court Costs Office or as notified to you in writing.

If you win your claim, we expect to recover some of our fees from your opponent.

If you win and for any reason we are unable to recover all of our fees from your opponent, you are responsible for the difference.

We confirm that if there is any shortfall between the fees recovered from your opponent and our fees, the maximum you will be required to pay us over and above the recovered sum shall not exceed a sum equivalent to 25% of any damages you have received. This cap does not include any fees payable to us for interim hearings or applications where the court has ordered payment by the opponent or another party.

If your claim is unsuccessful, we shall not charge our basic charges or success fee (except for those covered by insurance), provided that you keep to the terms of this agreement.

By signing this agreement and/or by providing continuing instructions, you (the client) agree that you will be bound by and will fulfill your part of this agreement and comply with the Terms & Conditions below.

Signature 1(Required)

Hidden

Our Ref:

Notice of the Right to Cancel

YOU MAY CANCEL THIS CONDITIONAL FEE AGREEMENT WITHOUT CHARGE, provided that you do so WITHIN
14 DAYS from the date upon which you received this notice from us.

If you wish to cancel the contract you MUST DO SO IN WRITING and deliver personally or send (which may be
by electronic mail) notice to the person named in the Cancellation Notice Form supplied with this agreement.
You may use that form if you want to but you do not have to.

FORM OF AUTHORITY FOR THE RELEASE OF PHOTOCOPIED MEDICAL RECORDS

I authorise Lincoln Lewis Solicitors and their nominated Consultant/agents to have access to all photocopied medical records, reports, films or other results of investigations held by any Doctor or Hospital whom I have consulted at any time which will assist the above named in the preparation of a Medico-Legal Report.

Title(Required)

Name in full:(Required)

Date of birth(Required)

Date of accident(Required)

DD slash MM slash YYYY

Full address and postcode(Required)

TELEPHONE NUMBER

Home(Required)

Work

GENERAL PRACTIONERS DETAILS

Name of GP(Required)

Name of surgery(Required)

Full address(Required)

CONSENT FOR GP RECORDS

I agree

I consent to the disclosure of photocopies of my COMPLETE GP records
I confirm that no action is contemplated against the GP, his/her partners or employees.
I confirm access is sought under the Data Protection Act 2018.

HOSPITAL ATTENDED

Name of hospital(Required)

Full address(Required)

REF:(Required)

Consent

CONSENT FOR HOSPITAL RECORDS

CONSENT FOR HOSPITAL RECORDS
I consent to the disclosure of photocopies of my Hospital Records and X-Rays
I confirm that no action is contemplated against the NHS Trust or its staff.
I confirm access is sought under the Data Protection Act 2018.

FORM OF AUTHORITY TO PROCEED

ACCEPTANCE OF TERMS OF ENGAGEMENT

Form of Authority to Proceed

Acceptance of Terms of Engagement

Before signing this form, please ensure you have read and understood the client care letter and the Lincoln Lewis Solicitors Terms of Business.

Your signing of this form of authority will be confirmation that you have read and understood the contents of the Client Care Letter and Terms of Business.

To: Lincoln Lewis Solicitors, Suite 1, Freckleton Business Centre, Freckleton Street, Blackburn BB2 2AL

I acknowledge receipt of the Client Care Letter and Terms of Business, which I have read and understood.

I hereby give notice that I instruct Lincoln Lewis Solicitors and give authority to Lincoln Lewis Solicitors to commence work with immediate effect, though this will not affect the cancellation rights which have been explained to me and that I understand.

I consent to any file or files relating to this matter being inspected by external auditors who may periodically wish to inspect Lincoln Lewis Solicitors’ files for the purposes of maintaining appropriate quality systems.

I CONSENT FOR FURTHER CORRESPONDENCE TO BE SENT VIA E-MAIL TO ___________

IF YOU WISH TO RECEIVE DOCUMENTATION BY POST CONTACT US IMMEDIATELY

I agree to the terms of this letter.

Signed

Name(Required)

Date(Required)

DD slash MM slash YYYY

Section M — Other relevant information

Other relevant information

Section N — Statement of truth

Your personal information will only be disclosed to third parties, where we are obliged or permitted by law to do so. This includes use for the purpose of claims administration as well as disclosure to third-party managed databases used to help prevent fraud, and to regulatory bodies for the purposes of monitoring and/or enforcing our compliance with any regulatory rules/codes

Untitled(Required)

I am the claimant’s legal representative. The claimant believes that the facts stated in this claim form are true. I am duly authorised by the claimant to sign this statement.

I am the claimant. I believe that the facts stated in this claim form are true.

Signed

Date

MM slash DD slash YYYY

Position or office held (if signed on behalf of firm or company

Consent

I have retained a signed copy of this form including the statement of truth.

Part E: The period the information should cover

Date From	Date To
2008	Present

DWP does not hold personal information indefinitely. It may be that some information has been destroyed in line with our data retention policies.

Part F: Consent – to be completed by the citizen or their appointee

DWP needs to make sure that you agree to the third party named in Part A being given your personal information.

Before you sign this form, you should check that the third party has fully completed the sections above and you understand exactly what information they are requesting.

Read the following statements carefully and then tick only one box to show your preferred option. We will not accept any requests where you have not selected an option.

Untitled

I want the information listed on this form to be sent to me and I will pass it on.

I agree that the information listed on this form can be sent to the third party.

Declaration

In signing this form:

I agree the information provided on this form is correct.
I understand what information has been requested by the third party and what will be provided to me or the third party.

Signed

Date(Required)

DD slash MM slash YYYY

FORM OF AUTHORITY

I HEREBY authorise Lincoln Lewis Solicitors to obtain a copy of my medical report from my previously instructed Solicitors in respect of my previous accidents. I also provide Lincoln Lewis Solicitors with authorisation to obtain pertinent details in respect of my accident from my previously instructed Solicitors. I believe the contents of this statement are true.

Signature

Date(Required)

DD slash MM slash YYYY

Ref

Documents Needed: We will require the following documents to support your case.

Driving Licence (Front & Back):(Required)

Drop files here or

Accepted file types: jpg, png, pdf, jpeg, Max. file size: 128 MB, Max. files: 2.

Insurance Certificate:(Required)

Drop files here or

Accepted file types: jpg, png, pdf, jpeg, Max. file size: 128 MB, Max. files: 4.

Logbook (Page 1,2,3 & 4):(Required)

Drop files here or

Accepted file types: jpg, png, pdf, jpeg, Max. file size: 128 MB, Max. files: 4.

Proof Of Address (Please provide 2 forms of proof of address):(Required)

Drop files here or

Accepted file types: jpg, png, pdf, jpeg, Max. file size: 128 MB, Max. files: 4.

(Bank Statements/ Utility Bills)

Main Claim Form

Driver / Passenger details

Vehicle Details:

Vehicle Owner Detail: (If Other)

Only fill in if applicable otherwise please skip

Injury Details

Accident Information

Third Party Details:

Other Vehicle Involved:

Accident Detail:

Witness 1

Witness 2

Description & Sketch of Accident

CONDITIONAL FEE AGREEMENT

What IS covered by the Agreement

What IS NOT covered by this Agreement

The Agreement

Notice of the Right to Cancel

FORM OF AUTHORITY FOR THE RELEASE OF PHOTOCOPIED MEDICAL RECORDS

TELEPHONE NUMBER

GENERAL PRACTIONERS DETAILS

HOSPITAL ATTENDED

FORM OF AUTHORITY TO PROCEED

Form of Authority to Proceed

Acceptance of Terms of Engagement

Section M — Other relevant information

Section N — Statement of truth

Part E: The period the information should cover

Part F: Consent – to be completed by the citizen or their appointee

Declaration

FORM OF AUTHORITY

Documents Needed: We will require the following documents to support your case.

@CLAIMWORKS

INFO@CLAIMWORKS.CO.UK

020 3772 0420

020 3772 0420

INFO@CLAIMWORKS.CO.UK

WWW.CLAIMWORKS.CO.UK

@CLAIMWORKS