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Are you:
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MM slash DD slash YYYY
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Did, or have you been told, that you will need surgery as a result of your injuries?
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I have been off work since the accident and continue to be unable to work
Please provide all known information relating to the party which you believe caused your injuries, if no information is known, please indicate “unknown” in your reply.
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Greenland
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Nigeria
Niue
Norfolk Island
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Paraguay
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Portugal
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Email (if different from above)
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Details of claim please tell us what happened, including dates
When did it happen?
Name(s) of the health care provider(s) who treated you
What do you think the health care providers did wrong?
Nature of injuries
Is your injury likely to be long term?
Yes
No
What type of injury do you have as a result of the medical treatment?
Please describe any of the physical activities that are now difficult to perform, including recreational and household tasks
Income loss were you employed before you were injured?
Yes
No
Has your injury impacted your ability to work?
Yes
No
How is your ability to work been impacted?
Cost of care
Do you have any ongoing medical expenses as a result of your injuries?
Yes
No
Please provide details
Have any family members had to spend time or money to help you with your care?
Yes
No
Please provide details
Insurance Law
Type of Insurance
--PLEASE CHOOSE--
Motor Vehicle / Accident Benefits
Property Damage
Commercial
Other
Other (please specify)
Type of Insurance - Add More Info
Type of Claim / Issue
--PLEASE CHOOSE--
Claim against your Insurance Company (coverage issue)
Denial of Coverage
Personal Injury
Subrogation
Advice regarding coverage
Other
Other (please specify)
Type of Claim / Issue - Add More Info
Value of Loss
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Less than $25,000
Between $25,000 and $50,000
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Between $100,000 and $200,000
Over $200,000
Value of Loss - Add More Info
Has the insurer provided a decision on the claim?
--PLEASE CHOOSE--
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No
Pending / In Progress
Additional comments or details about the claim
