McKinley Law - CRIMINAL INJURY CLAIM FORM

CRIMINAL INJURY CLAIM FORM

Part 1: YOUR PARTICULARS
Full name:
Address:
Email:
Telephone:
Date of birth:
Occupation:

Part 2: PARTICULARS OF INCIDENT CAUSING INJURY
Approx. date and time of offence:
Place of offence:
Type of offence:
Was the offence reported to Police?	Yes No
Did the Police attend the incident?	Yes No
Do you know the name/address of the offender?	Yes No
Was anyone charged with a criminal offence?	Yes No
Were there any witnesses to the incident?	Yes No

Part 3: DETAILS OF INJURIES
What injuries did you sustain?
Were you hospitalised following the incident?	Yes No
If not, did you consult your medical practitioner following the incident?	Yes No
Please provide details of treatment administered:

Part 4: DISABILITIES AND EFFECTS OF THE INCIDENT
How have your injuries affected you?

Part 5: LOSS OF EARNINGS/EARNING CAPACITY
Are you:	employed full time employed part time/casual self employed retiree/pensioner unemployment/sickness benefits
If applicable, period of absence from work due to injury: