Second Floor Barlow House Minshull St Manchester M1 3DZ Tel: 0161 906 0789 Fax: 0161 906 0799 Email: neil@neil-millar.co.uk

Accident Report

Accident Report Questionnaire Please complete the form, click submit and we will contact you as soon as possible. Full Name: Address: Telephone Home: Telephone Work: Mobile: Occupation: Date of Birth: / / (dd/mm/yyyy) What date did the accident occur?: / / (dd/mm/yyyy) What type of accident was it? i.e., Road traffic accident / accident in the home / at work / or other, please specify. Where did the accident happen? Please describe what happened.