ATL Injury Registration Form
Complete all fields as fully as possible
Full Name
Membership Number
Address
Daytime Telephone
Evening Telephone
Mobile:
Email Address
What is your date of birth?
Date of the Accident
(Date of onset of symptoms in disease cases)
If an accident, was the accident
:
Work Related
On the Road
Trip or Slip
Other
Tell us a little about your accident / occupational disease
Address:
Who do you think was at fault?
Name:
Address:
Why do you hold that person/organisation responsible?
What Injuries did you suffer?
Please note that submission of this form will only allow one of our solicitors to contact you for full instructions and to advise upon the merits of your claim. No retainer is established and no instructions are accepted by Morrish & Co until we have confirmed acceptance of instructions in writing..
IMPORTANT
A claim for personal injuries must be brought within 3 years of the accident date, except in certain limited circumstances e.g. claims by children. If you are aware that the time limit in your case is soon to expire then please do not use this form, but instead telephone on 0113 245 0733 to discuss your claim. Delay almost always proves fatal to a claim.
Morrish & Co solicitors can accept no responsibility for the expiry of time limits due to the delay in the submission of instructions, or failure of email delivery. If you have not heard from us within 2 working days of submission of this form, please telephone us on 0113 245 0733.
I have read and understand the information set out above
( required )
