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Name

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Brief details of accident

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Please submit as much information as you can. The more information you submit, the quicker our experts will be able ascertain whether or not your claim has reasonable prospect of success.

Type of injury

Please select what type of injury you have sustained.

Road Traffic Accident

Industrial Injury or Disease

Trip or Slip

Medical negligence

Fatal Accident

Criminal Injury

Your details

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Full name *

 

Date of Birth *

  /   /  

National Insurance No.

 

Address

 

Post Code

 

Daytime Telephone No *

 

Email address *

 

Do you have any Legal Expenses Insurance on any existing Insurance Policies, eg motor, home, credit card etc?

 

Are you entitled to Legal Expenses Insurance under somebody else’s Policy?

 

How did you hear about Harding Evans?

 

Claim information

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Date of Incident

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Please give brief details of circumstances of incident *

 

Please give details of the injuries sustained *

 

Harding Evans LLP will not pass your details on to any third parties and all information sent is confidential

 

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Harding Evans is a trading name of Harding Evans LLP.