Step 1: Complete the personal details of the CLAIMANT. If you are completing the form on someone else's behalf, you must fill the form with their details not your own. If you are completing for multiple claimants, then separate forms must be completed for each claimant.
Step 2: Fill in your personal GP details. If you do not know the name of your GP then specify 'GP Name' as 'Unknown' but GP practice details are still required. If you are not registered with a GP practice then you must register with a local practice in order to complete this part of the form as it cannot be left blank.
Step 3: If you were treated at any hospitals, walk-in centres, clinics or received treatment in relation to your accident, then you would provide those details in this section, including any scans or x-rays taken.
Step 4: Use this part of the form to give details of any other hospitals or treatment providers, if applicable.
Step 5: Read the declaration and sign it. You can sign the form on mobile and tablet devices using your finger or a stylus. If you make a mistake on your signature, just tap the clear button to start your signature again. - NOTE* If you are using a laptop device, click the left button in and hold whilst making your signature with the touch pad.
Step 6: Date the form, and complete the captcha by typing the word provided in the box, if you cannot see the word in the box click the refresh symbol to the right of the box to receive a new word. Once done, click submit. Our forms are encrypted for your data's protection.
Step 7: That's it, you're all done! You should see the image below after clicking submit. Now your completed form will be passed to the Medical Agency who are dealing with your claim.