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Compensation Claim Form CRU1 12/20, Study notes of Sign Language

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.

Typology: Study notes

2021/2022

Uploaded on 09/12/2022

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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
pf3
pf4
pf5

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CRU1 12/

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

Page 2 of 6 CRU1 12/

About the injured person continued

  1. Title For example Mr, Mrs, Miss, Ms.
  2. Gender

Female

Male

  1. Date of birth - DD/MM/YYYY
  2. Date of death (if applicable) - DD/MM/YYYY
  3. Address including postcode

Reason for claim

  1. Please tell us the date of the accident or alleged clinical negligence.

DD/MM/YYYY

Page 4 of 6 CRU1 12/

About the compensator

  1. Name of compensator or compensator’s representative
  2. Full postal address
  3. On behalf of: (enter name of compensator if representative’s details given above)
  4. Your reference (maximum of 24 characters)
    1. Name of insured or policy holder or car registration
  5. Telephone number

About the injured person’s representative

  1. Name of representative
  2. Full postal address
  3. Your reference (maximum of 24 characters)

CRU1 12/20 Page 5 of 6

About the injured person’s representative continued

  1. Telephone number

About the hospital(s) attended because of the

accident or incident

  1. Did the injured person receive NHS treatment because of the incident?

No

Yes

Not yet known

  1. Is the compensator the same as the Trust?

No

Yes (^) If Yes , do not complete hospital details.

Please list the hospital(s) in the order the injured person attended.

  1. Name of first hospital (if applicable)
  2. Address including postcode (if applicable)
  3. Name of second hospital (if applicable)
  4. Address including postcode (if applicable)

If further hospitals attended please provide details on a separate sheet.