"*" indicates required fields Step 1 of 7 14% Which of the following best describes the injury or accident that you or your family member were involved in?* I was injured at work I was injured in a motor vehicle accident I was injured in a public place I was injured as a result of negligent medical treatment I was injured as a result of abuse or an assault I was injured due to exposure to dust or other hazardous material When did the accident occur? (If you do not know the precise date, please provide your best estimate)* MM slash DD slash YYYY Please describe how the accident or injury occurred.* As a result of the injury or accident, did you or a family member experience any of the following?* Psychological Injury Physical Injury Loss of Life As a result of the injury or accident, did you or a family member experience any of the following?* Injury to spine Injury to hip / knee / ankle Injury to shoulder / elbow / wrist Loss of body part / amputation Head injury Other Please select if you or a family member have had any of the following medical treatments.* Admission to Hospital Physiotherapy Psychological Treatment Medication Specialist Consultations Surgery Radiological Investigations (X-rays and scans) Other Has the injury or accident impacted the ability to work?* Yes No Please Specify* Thank you for completing your Free Compensation Claim Check. We will be contacting you shortly to discuss your potential claim.Your Name*Email* Phone*