GMB Birmingham & West Midlands Region

Personal Injury Claim Form

	Section 1: Members Details
Surname:	* required
First Name:	* required
GMB Membership Number:	* required
Date of Birth:
Gender:	Male Female
Home Address:	* required
Address 2:	* required
Town:	* required
Postcode:	* required
Home Telephone:	* required
Work Telephone:
Mobile:
Email Address:	* required
Employers Name:
Employers Address:
Address 2:
Town:
Postcode:
	Section 2: Claimant's Details if different from member
Surname:
First Name:
Date Of Birth:
Gender:	Male Female
Home Address:
Address 2:
Town:
Postcode:
Home Telephone:
Work Telephone:
Mobile:
Email Address:
Relationship to Member:
	Section 3: Accident or Disease Details
Date of Acciddent:
Date of onset of Disease:
	Section 4: Details of the cause of the Accident/Disease
Please describe the circumstances of the accident, including where it happened and what you were doing at the time.
If it is a disease, please provide details of the substances or work process you consider responsible.
	Section 5: Disease symptoms or injuries
Describe your injuries or symptoms of disease
I agree to the terms and conditions as stated above	Please tick, if you do not agree to the Terms and Conditions your claim will not be submitted