Occupational Disease Claim

Please register your claim below and book your appointment online.

The details you provide will then be considered by a senior solicitor and your appointment will be confirmed. If for any reason we are unable to proceed with your claim, you will be notified immediately and the appointment will be cancelled.

We will endeavour to contact you and confirm your appointment within 4 working hours of receipt.

Please only complete this form if you have obtained a relevant diagnosis from your General Practitioner and/or Specialist.

Browell Smith & Co Solicitors
Free Consultation, No Obligation, 100% Compensation

Your Name

Address

City/Town

County

Postcode

Date of birth

Date of Birth :: Please enter the date in the format DD/MM/YYYY

NI Number

National Insurance Number :: If you can't remember your number, you may find it on official paperwork, eg;
- your end of year tax statement (P60)
- a payslip
- a copy of your annual tax return
Otherwise, contact your local Jobcentre Plus, social security office or HM Revenue & Customs (HMRC) NI Contributions Office.

Telephone No.

Email

Email :: Please enter a valid email address e.g. yourname@service.com

Please only complete this form if you have obtained a relevant diagnosis from your general Practitioner and/or Specialist.

Browell Smith & Co Solicitors
Free Consultation, No Obligation, 100% Compensation

Date you first suffered from symptoms

Symptoms Date :: Please enter the date in the format DD/MM/YYYY

Date of doctors diagnosis

Symptoms Date :: Please enter the date in the format DD/MM/YYYY

Who do you blame for your condition?

Who do you blame :: Please list one or more previous employers

Would you prefer a home visit?

Yes No

(Limited home visits are also available on a Saturday)

Please select your preferred home visit date

Home visit date

 

Browell Smith & Co Solicitors
Free Consultation, No Obligation, 100% Compensation

Source Choose Option Television Advert Radio Advert Newspaper Advert (please specify) Union Referral (please specify) Yellow Pages Mail Shot Respondent Recommendation Former/Existing Client (quote reference) Internet (please specify website/search engine) Other (please specify)

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Click to submit your application