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Claim Enquiry Form

Claimant Details

1. Title: Mr Mrs Ms Miss
2. Full Name:
3. Telephone No. (Home):
4. Telephone No. (Mobile):

1. Type Of Claim: Driver/owner of a car in an accident. Passenger/pedestrian in a car accident. You had an accident at work. You had a slip. You had a trip. Other claim
2. What was the date of incident: Last 6 Months 6 To 12 Months Ago 1 To 2 Years Ago 2 To 3 Years Ago

Call me back

Call Back Details

1. Name:
2. Contact Telephone No.:
3. Accident Type: Accidents / Illness abroad Accidents at work Animal attacks Criminal injury Cycling accidents Faulty products Major disasters Medical negligence Professional negligence Public Liability Road traffic accident Slipping and tripping Sport / leisure injury Work-related disease
4. Time To Call: Today Tomorrow Morning 9-11 Lunch 12-2 Afternoon 3-5 Evening 6-8

Submit Form

Contact Us

• 0161 764 1845
• info@northwestclaims.co.uk
• N.W.C.B LTDDerby Chambers 6The Rock BuryBL9 ONT

Northwest Claims Bureau is regulated by the Ministry of Justice in respect of regulated claims management activities; its registration is recorded on the website www.claimsregulation.co.uk. Authorisation number : CRM16143
Company registration number 6703536, Northwest Claims is compliant under the data protection act 1998 under the ICO (Z1804700).