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A compensation claim form for accidents or incidents, outlining the mandatory requirements and information needed for registration. It includes sections for the injured person's details, reason for claim, accident details, compensator details, injured person's representative details, and hospital details. Regulations from the Social Security (Recovery of Benefits) Regulations 1997, Road Traffic (NHS Charges) Regulations 1999, Personal Injuries (NHS Charges) (General), and Road Traffic (NHS Charges) (Amendment) Regulations 2006 are referenced.
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Mandatory requirements
Please answer all questions. If this form is not completed correctly we may not be able to register the claim.
These are set out in:
Please use BLOCK CAPITALS if you are filling in this form with a pen.
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About the injured person continued
Female
Male
Reason for claim
DD/MM/YYYY
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About the compensator
About the injured person’s representative
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About the injured person’s representative continued
About the hospital(s) attended because of the
accident or incident
No
Yes
Not yet known
No
Yes (^) If Yes , do not complete hospital details.
If further hospitals attended please provide details on a separate sheet.