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

Employment details Employer name Employer address Start date End date Job description Do you have any objection to the Asbestos Claim Centre submitting your details to one of our expert lawyers with a view to assisting you with the potential claim for compensation? " No " Yes

This claim form is for relatives wishing to make an asbestos compensation claim on behalf of a deceased next of kin.

Your Details ... Name:
Phone:
Email:
Address:
Please contact me by:

Deceased Details ... Relation ship with deceased:
Deceased name:
Date of birth:(dd/mm/yyyy):
Date of death:(dd/mm/yyyy):
Was a post mortem carried out?:
Which of the following was the deceased diagnosis with?:
If 'other', please specify:

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

Information Consent ... May we pass your details to our panel of lawyers for assessment?:

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

Next of Kin Asbestos Compensation Claim Form