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Notice of Accident Claim Form

Notice of Accident Claim Form

Before we can bring a claim for accident compensation on your behalf, we require you to complete our Accident Claim Form below.

Upon receipt of your completed Accident Claim Form one of our team will contact you to discuss your potential claim for compensation. Please note that all questions with an * should be completed.

Medical Certificate

Before we can finalise your Accident Claim Form, you will need to have your general practitioner (doctor) complete a Medical Certificate. The Medical Certificate is available in the Accident Forms download area of our website. Before you see your general practitioner please make a list of all of the areas of your body that are painful and sore as a result of the accident and make sure that your general practitioner specifically refers to each of the painful areas of your body on the medical certificate. The insurer will only pay for the treatment on the areas of your body that are specifically referred to on the Medical Certificate. Please also ensure that your general practitioner includes a referral on the Medical Certificate for physiotherapy, psychological counselling, orthopaedic specialist or any other medical specialist as appropriate.

Claim type
Injured persons details
Have you made an application to the National Injury Insurance Scheme Queensland?
Are you a participant in the National Injury Insurance Scheme Queensland?
Do you have any personal injury, illness or disability (either before or since the accident) that may affect the extent of the disability resulting from the personal injury to which this claim relates or may affect the amount of damages in any other way?

Significant disability means any personal injury, illness, or disability that either;

1) May be relevant to the assessment of the extent of the injury suffered by the injured person in the accident; OR

2) The symptoms lasted for four (4) weeks or more.

Accident details
Include name of nearest cross road or property number Address
Type a brief description
Did you consume or use any alcohol or drugs in the last 12 hours before the accident?
Please describe
Please describe
Please describe, for example: Vehicle 1 (the vehicle at fault) caused the accident by colliding with the rear of Vehicle 2.
Please describe, for example: Vehicle 2 was travelling north on Beach Road. Vehicle 1 (the vehicle at fault) was also travelling north on Beach Road following Vehicle 2. The vehicles in front of Vehicle 2 braked suddenly and came to a complete stop. Vehicle 2 also came to a complete stop. Vehicle 1 then failed to stop in time and collided with the rear of Vehicle 2.
Acceptable file formats PDFs, bitmap images, word documents and .zip files. If the total file size of your documents exceeds 10mb, please compress them into a zip file first before upload.
Vehicle 1 details
Vehicle 2 details
e.g. Ford
e.g. Laser
e.g. Sedan
Other vehicles involved
Vehicle 3 details
e.g. Ford
e.g. Laser
e.g. Sedan
Vehicle 4 details
e.g. Ford
e.g. Laser
e.g. Sedan
Witness details
Police report
Employment at date of accident
Have you lost or will you lose wages, salary, business or other income because of the accident?
Additional information
Once you press the submit button a copy of your online Accident Claim Form will be emailed to your email address and Injury Lawyers Queensland. Once your Accident Claim Form is received one of our team will contact you shortly to discuss your potential claim for personal injuries.

 

Injury Lawyers Queensland

A division of Litigation Law Queensland
We are passionate about helping people who have been involved in motor vehicle accidents and we love to exceed client expectations.

1800 777 099

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