CICA Personal Injury Claim Form

Abuse and assault extended enquiry form

Your Story - Your Experiences

Never too late to tell.
11/04/2019        Anonymous


Held at knifepoint at building society robbery
20/02/2019        Anonymous


1979 Rule – How is that fair or just?
21/08/2018        Anonymous


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.

Title
First Name(s)
Surname
Your Address
Postcode
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
Occupation
Do you have any previous criminal convictions?
If yes, please provide more details and include dates of any known convictions
Have you made a previous application to the CICA in relation to this particular incident?
Please provide your GP contact details
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
Did you attend hospital?
If yes, provide the time you attended the hospital
If yes, provide the date you attended the hospital
If yes, which hospital did you attend?
How was treatment provided?
Have you sought any further treatment for your injuries?
If yes, please state treatment and scheduled dates (if known)
Have you been or are you expected to be unable to work for 28 weeks or more?
Date of incident (if known)
Approximate time
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.
Relationship? / Acquaintance? Did you report the matter to the police?
Date of report
Time of report
Police branch
Branch address
Full address including post code Crime reference 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
Declaration
I believe that the facts stated in this questionnaire are true and accurate to the best of my knowledge. Thank you for taking the time to complete this questionnaire. 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.
Have you received compensation from the courts or any other body relating to this matter?
If yes, how much did you receive?
Date received
Who was this compensation awarded by?