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(CICA) Criminal Injuries Online Claim Form

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Personal Details:

FULL NAMEyour full name
DATE OF BIRTHyour date of birth
TELEPHONEyour telephone/mobile number
ADDRESSfull address
EMAILa valid email address
NATIONAL INSURANCE NUMBERNational Insurance Number

Incident Details:

INCIDENT DATEIncident Date
INCIDENT TIMEIncident Time
INCIDENT ADDRESS/LOCATONincident address/locaton
NAME OF PERSON WHO INJURED YOU?name of person who injured you?
INCIDENT DETAILincident detail
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CRIME REFERENCE NUMBER

Injuries Sustained:

DESCRIBE YOUR INJURIES
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www.cica-criminal-injuryuk.com is owned and operated by Higgs Newton Kenyon Solicitors. Higgs Newton Kenyon Solicitors is a trading name of UK Law Nationwide Ltd which is registered under England and Wales under number 08307355. Registered office, 6th floor, Yorkshire House, 18 Chapel Street, Liverpool, L3 9AG. A list of directors is open for inspection at the registered office. Regulated by the Solicitors Regulation Authority under number 573571.