Fire Brigades Union Personal Injury Application

Workplace

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Personal Injury Application Form:

This Application is sent direct to Thompsons Solicitors Logo NOT via the FBU

ALL FIELDS are required
( A Copy of this message will be sent to your E-Mail Address below )

Email Address
Membership Number
Salutation	First Name	Surname
Address
Postcode
Date of Birth	dd mm yy

Home Phone
Work Phone
Mobile Phone
Best Contact	Home Work Mobile

Brigade
Brigade HQ Address
Workplace Address

Date of Accident: dd mm yy
Type of Accident
Injuries sustained
Did you visit Hospital Yes No
What treatment did you receive?
Have you had any X-Rays taken? Yes No
Have you had any time off work? Yes No
Who was too blame?

When the forms is received you will receive a call back usually the same day with the exception of weekends. If the you are not available a message will be left giving you our (Thompsons) office number asking you to contact us.