Claim Form for Asbestos-Related Injury and Disease from the Asbestos Claim Centre

This detailed claims form will enable the Asbestos Claim Centre to make a full assessment of your potential claim.

Personal Details ... Name:
Date of birth:(dd/mm/yyyy):
Phone:
Email:
Address:
Please contact me by:

Your Doctor's Details ... GP name:
Surgery address:
Surgery postcode:
Surgery telephone:

Your Employment Details ... Employer name:
Employer address:
Start date:(dd/mm/yyyy):
End date:(dd/mm/yyyy):
Job description:

Your Injury ... When did symptoms first occur? (dd/mm/yyyy):
I have been examined by a medical expert:
I was diagnosed with the asbestos illness:
If 'other', please specify:
My injury was work-related:
Date of my diagnosis (dd/mm/yyyy):
May we pass your details to our panel of lawyers for assessment?:

Thank you for submitting your asbestos compensation claim. We will assess your claim as soon as possible and then contact you to discuss the next steps.

Detailed Asbestos Compensation Claim Form