CRU1 12/20
A claim for compensation
because of an accident or incident
We have many different ways we can communicate with you
If you would like braille, British Sign Language, a hearing loop, translations, large print,
audio or something else please tell us.
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:
• Regulations 3, 6 and 7 of the Social Security (Recovery of Benefits) Regulations 1997,
and
• Regulation 7 of the Road Traffic (NHS Charges) Regulations 1999, and
• Regulation 5 of the Personal Injuries (NHS Charges) (General), and Road Traffic
(NHS Charges) (Amendment) Regulations 2006.
Please use BLOCK CAPITALS if you are filling in this form with a pen.
About the injured person
1. National Insurance (NI) number
2. Surname
3. First forename
4. Other forename(s)
5. Any other known surname(s) for example
maiden name
