PUBLIC LIABILITY CLAIM FORM

Full Name (required)

Telephone Number (required)

Address

Postcode

What was the Accident Location

Date of Accident

Defendants Name and Address

Postcode

Do you visit the location oftenYesNo

How long had the defect/substance been there

What footwear were you wearing

Circumstances of the Accident

Who do you believe was responsible for the accident
and why?

Were there any witnesses ? If so please provide
their details

Has the matter been placed in an Accident Book/Reported to anyoneYesNo

If so, where was it reported to

What injuries did you sustain