LIABILITY CLAIM QUESTIONNAIRE

Transcription

1 Transport for London Please complete and return to: Gallagher Bassett Ltd., PO Box 42501, London E1 1YB. LIABILITY CLAIM QUESTIONNAIRE Thank you for advising us of your intention to claim damages for an incident on Transport for London s network. Gallagher Bassett International Ltd are appointed by TfL to investigate and assess liability claims made against us. In order to assess your claim for compensation, please complete the following Questionnaire as fully as you can and return it to Gallagher Bassett. The circumstances of your accident will be investigated and if TfL are judged to be liable, Gallagher Bassett shall see the process though to settlement. Depending on the size and nature of the claim you may need to provide further information. There is no guarantee that compensation is due to you and provision of this Questionnaire does not constitute an Admission of Liability by TfL, but failure to provide information will delay your claims consideration and / or lead to its rejection. The decision to offer Damages will be made based on the facts and the law. It is your responsibility to demonstrate and prove your Claim. You may wish to take your own independent legal advice. Transport for London support the Government s Anti-Fraud Initiative and exchange data with other organisations. Fraudulent Claims will be viewed with a mind to Prosecution How to Complete this Questionnaire Sections 1, 2 & 6 are compulsory and are to be completed by all claimants Complete either section 3 and / or 4 as appropriate Complete Section 5 if you wish This questionnaire is generic and not all parts will be relevant to your claim, but please provide as much information as you can. If you have information that you think is relevant, but not specifically asked for, please provide it. If you have any queries regarding the completion of this questionnaire, or progress of your Claim, please contact Gallagher Bassett at the address above, or telephone This Questionnaire is not for Underground service disruption or for Lost Property Claims, for these go to Issue 2

2 Notes to Claimants On receipt of your completed Claim form, we will write to you within 21 days to confirm its receipt. The law allows up to three months to consider your claim and to tell you if we accept that we are responsible and liable or that we don t. If we don t, we ll explain why not. In either case, you will be contacted with a decision and explanation as quickly as possible. If we don t accept that TfL is responsible, compensation will not be paid. If you wish to discuss this, please telephone the Claims Adjuster at Gallagher Bassett. If we accept that TFL are responsible, you will receive a letter confirming so and if all the information is available, a fair offer of compensation will be made. If more information is required you will be asked for it. Should you wish to accept the offer, please write to the Claims Adjuster confirming this. Please quote their claim number on your letter and say who the cheque should be payable to. It usually takes two weeks to receive it. Gallagher Bassett will consider the evidence provided by you and collected from TFL and will decide if a liability exists. What You Will Have to Do. You will have to provide suitable evidence to support your claim. You will have to show to Gallagher Bassett that you did suffer a loss or an injury. If you are making a claim for an injury, a medical report will need to be obtained. You will be asked to permit Gallagher Bassett to talk to your GP or see hospital records. Delays often occur at this stage, and you can help by chasing your GP or hospital. For severe injuries, a report may be obtained from a consultant and this may take a few months. If your claim is for damage to property, such as clothing, you should provide the following: If available, the purchase receipt for the damaged item an estimate for its replacement proof of ownership confirmation of the age of the damaged item. The reason why you are asked for the age of the item is because compensation takes into account wear and tear. If the damaged item is repairable, two quotes for it s repair If you have photographs or information that you feel may be helpful to Gallagher Bassett when considering your claim, would you please send these to them as quickly as possible. Always quote Gallagher Bassett s claim number when writing about your claim. This will help to speed the process. You are entitled to take legal advice in relation to your claim at any time. If you disagree with the decision on liability then you may seek legal advice and take the matter to Court. It must be emphasised that although an accident may have happened, there is no automatic entitlement to compensation. The accident may not be TFL s fault. Printed on environmentally friendly paper

3 SECTION 1: YOUR DETAILS Forename Surname Address for Correspondence (incl post code): Telephone: - home - mobile - work Please tick which is preferred for calls during working hours Date of Birth, if an Injury is alledged DD/MM/YYYY Employer s Name and Address Clock / Works / Employee Number National Insurance Number Have you ever made a claim for damages against Transport for London, London Underground, London Transport or any other Local Authority? If yes, who delete one If you have a Representative, for instance a Solicitor or Insurer, please provide their details Name Address Telephone number Their Reference, if known - Page 2 -

4 Section 2: DETAILS OF ACCIDENT Date and Time of Accident Location -Road or Bus accident adjacent house number / shop name / park / road name -Underground accident Station name, or where the train was. DD/MM/YYYY HH : MM am / pm Please sketch the area where the accident happened. e.g. direction of travel, signs, where in the station, vehicle positions - Anything to help us understand the location and circumstances. Please describe how the accident happened and its cause. Were there any witnesses? 1 2 If yes, please give their Names and Address and state if they are related or otherwise known to you - Page 3 -

5 Section 2 continued Were others informed? e.g. Underground Station, Council name or Police. If yes, please provide details, including date, contact name and reference. 1 2 If you were on Public Transport, did you use an Oystercard? If yes, what is its number? Did you take photo s of the accident site? When were they taken? DD/MM/YYYY If yes, Please attach them to this form. SECTION 3: DETAILS OF PROPERTY DAMAGE What was damaged? When & where was the damaged item(s) bought? (Please provide receipt if available) Note: keep the item, we may wish to view it. If you have repaired or replaced the item please attach receipt. - Page 4 -

6 SECTION 4: DETAILS OF ANY PERSONAL INJURIES Describe your Injury: Did you go to Hospital? If yes, please give the Name and Address (we require a copy of the Emergency Treatment Slip): Did you go to a Doctor? If yes, please give the Doctor s Name and Address - Page 5 -

7 SECTION 5: ANY OTHER INFORMATION Please provide any other information to assist us to understand and investigate the incident and to consider your claim. - Page 6 -

8 SECTION 6: STATEMENT I*, the Undersigned, confirm that the information given in this form is true and complete to the best of my knowledge and belief. Signature: Print Name Date: * If the person who had the accident and is claiming damages is under the age of 18, a parent or guardian should complete and sign this questionnaire and state their relationship, and the claimant complete the following declaration. I confirm that the above named person is my Parent / Guardian (delete one) and is acting upon my behalf Signature: Print Name Date: Data Protection Act 1998 Information collected on the form shall be used by Transport for London for its own purposes and by and it s appointed agents to investigate the incident described. If you are acting on behalf of another person, The Claimant must confirm that you are appointed by them and that they have consented to the processing of their personal details. If appropriate and the Claimant has not consented, tick this box - Page 7 -