Armed Forces Compensation - PARKER THOMAS SOLICITORS

Date of Instructions:

Title: *

First Name *

Last Name *

D.O.B: *

Address: *

Postcode: *

Contact No: *

Email: *

NIN:

Occupation:

Have you previously claimed under WPS or AFCS?

Yes
No

Have you received AFCS Fast Payments:

Yes
No

Which Armed Forces Pension Scheme are you a member of:

Name in service

Service Number

Service Branch

Current rank or rank on discharge

What is or was your trade

Date of Enlistment

Date of discharge

Reason for Discharge:

Address of your current or last Service Unit

Injuries and date condition started?

Why you feel it was caused by service:

Did you attend GP?

If Yes, Date attended:

Name & full address of GP:

Did you attend Hospital?

If Yes, Date attended:

Full address of Hospital:

Was this a road traffic incident?

If yes, what was the route of the journey?

Why did you make the journey?

Did you have authorised leave at the time?

Was there any police involvement? If yes what are the details of this.

Were there any witnesses/ passengers? If yes what are their details.

Was the incident was a sporting activity, such as adventure training or physical training?

If yes, was the activity organised by the armed forces for you to represent your unit?

If yes, what was the activity?

Are there any witnesses? List their details.

Was any treatment given at the time of the injury?

Are you claiming for a condition/injury/illness that you believe started over a period of time?

If yes, when did this start / approximate date?

What do you believe caused this? For example, trade, duties, training, noise etc

If you believe it was from exposure to chemical or harmful substances, what were they?

Relating to the above, what date were you exposed and for what length of time were you exposed for?

When did you first seek medical attention?

Third Party Title:

Third Party Name:

Third Party Address:

Are you claiming or have you received compensation from the MOD regarding your injuries?

What conditions are you / have you claimed compensation for?

What was the outcome of your claim? Reference number:

Did you receive any payment?

Amount:

Date:

Was this interim or final settlement?

Solicitors details:

Are you in receipt of any benefits? If so, which ones? E.g. PIP, DLA, Universal Credit

If you receive IIDB, what conditions did you claim to receive this?

Name:

Address:

Contact NO:

Name:

Address:

Contact NO:

Name:

Address:

Contact NO:

Checkboxes

I confirm that the information provided is correct and true to the best of my knowledge.

Supplier Reference: