CICA Personal Injury Claim Form

Abuse and assault extended enquiry form

Important information for you

Your Story - Your Experiences

Raped by so called friends
03/01/2021        Dee

my uncle sexually touched me
06/11/2020        Anonymous

Hammer attack
30/10/2020        EH

More stories

Tell us more about your case

Please complete our form below to provide more detail about your circumstances. We will immediately assess your potential claim and advise whether you have a case.

    First Name(s)
    Your Address
    Primary contact phone number
    Is your contact number home, mobile or work?
    Additional contact phone number
    If you have any additional contact numbers, feel free provide them

    Is your secondary contact number home, mobile or work?
    Email Address
    Date of birth
    Town of birth
    Marital Status
    Do you have any previous criminal convictions?
    If yes, please provide more details and include dates of any known convictions - IMPORTANT
    Have you made a previous application to the CICA in relation to this particular incident?
    Please provide your GP details practice address
    Did you visit your GP about the incident(s)? If so on what date (approximate date is fine)?
    Please list the injuries or psychological symptoms caused by the incident(s)
    Describe more about the impact of the event(s) on you personally. Ie: on your life, work, relationships etc
    Have you been or are you expected to be unable to work for 28 weeks or more?
    Date of incident (if known)
    Approximate time if relevant
    Please describe clearly what happened
    Exact place of the incident
    Name of person(s) responsible for your injuries (if known)
    State whether this person / these individuals are known to you.
    Did you report the matter to the police?
    Date of report (approximate date fine)
    Time of report (if relevant)
    Police Authority (Area)
    Police branch address
    Full address including post code Crime reference or police office in charge if known (IMPORTANT)
    Did you make a formal police statement?
    Have you attended court?
    If yes, please provide the court date
    If you have not attended court, please explain why
    I believe that the facts stated in this questionnaire are true and accurate to the best of my knowledge. By pressing the SEND button below you are sending this form directly to the Criminal Claims Bureau. Your data is confidential and is protected, we do not share your personal details with any other body. The person who will be handling your claim will contact you shortly.