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Criminal Injuries Compensation Online Application Form

Criminal Injuries Compensation Online Application Form

Injured person details

Please provide details of any previous name(s) you may have used (e.g. maiden names)
Injured person's date of birth
Injured person's gender

Residency statements

Incident details

What time and date did the incident occur?
This question must be answered
This question must be answered

Reporting details

When was the incident reported?

Name and address of the police station where the incident was reported

Injury details

What injuries did you receive? (please list up to 5 below)

Medical details

It is important we have details of your GP even if you did not see them about the incident. Your GP will hold medical information which we may need to access.

GP details

Accident & Emergency details

Hospital details

Dentist's details

Other treatment

Previous applications

Criminal convictions

Additional information

I agree to the use of this information in accordance with the Winston Solicitors privacy policy from time to time in force.

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