For both confidentiality and privacy reasons, by simply clicking on the print button just below you can print out this form. You can complete it with your details (in block capitals throughout please), subsequently faxing or posting it to the number or address given below.

Alternatively it can be completed on line and, by clicking on the submit button below it will be forwarded directly to ourselves by E-mail.

Your Details:-

Full Name :

Address :

Postcode :

Telephone Nos. :

Day

Evening

Mobile

Fax Number :

E-mail :

Questionnaire :-

Brief details of Injury / Injuries:
Date of Assault / Incident:

Please click the appropriate boxes.
Did you attend a hospital (or doctor) for treatment after the incident?
Have you already submitted a claim form to the CICA?
Did you immediately report the incident to the police?
Have you or are you likely to lose earnings for more than 28 weeks?
Are you still injured or left with scar(s) or a disability?

How would you like us to contact you in future?	Telephone

	Fax:
	E-mail:
	Post:

How did you hear about us (please click or complete the appropriate boxes):-

Web Search :
Leaflet :
Brochure :
Business Card or Sticker
Newspaper (which one) :
Referral - Please state what organisation or individual

Other - Please give details

Press Submit to send this form to us by e-mail

Assault & Criminal Injury Compensation Associates Limited is a registered data user. Data supplied will only be used in connection with our Claims Processing Services and will not without your prior agreement be supplied to any other unconnected organisations. Data Protection Act 1998 Registration Number Z5910190.

The company is registered in England (No. 4085850).

You should be aware that there may be some risks in transmitting your unencrypted details and answers across the Internet. ACICA unfortunately cannot assume any responsibility for misuse of such information that may result from this transmission.

Telephone: 0800 61 91 483

Fax: 0870 011 0551

Address:

Suite 164, 14 Clifton Down Road, Clifton, Bristol BS8 4BF.

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Legal services company informing, guiding and providing advocacy plus accountancy specialist help on compensation claims from the CICA for injury victims of criminal assault, on an authentic no win, no fee basis.

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