Equity Registration Form

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Registration Form

Equity Injury Registration Form

Full Name

Membership Number

Address

Daytime Telephone

Evening Telephone

Mobile

Email Address

What is your date of birth?

Date of the Accident

(Date of onset of symptoms in disease cases)

If an accident, was the accident:

Work Related On the Road Trip or Slip Other

Tell us a little about your accident or occupational disease

Who do you think was at fault?

Name:

Address:

Why do you hold that person or organisation responsible?

What Injuries did you suffer?

IMPORTANT
A claim for personal injuries must be brought within 3 years of the accident date, except in certain limited circumstances e.g. claims by children. If you are aware that the time limit in your case is soon to expire then please do not use this form, but instead telephone on 0113 245 0733 to discuss your claim. Delay almost always proves fatal to a claim.

Morrish Solicitors LLP can accept no responsibility for the expiry of time limits due to the delay in the submission of instructions, or failure of email delivery. If you have not heard from us within 2 working days of submission of this form, please telephone us on 0113 245 0733.

I have read and understand the information set out above

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