1. Were you injured in the last 3 years?
2. Type of injury
Accident at workRoad traffic accidentSlip/tripSerious injuryFatal accidentDefective productMotorbike accidentOther
3. How severe was your injury?
4. Was the accident your fault?
5. Did you receive medical attention?
6. Where was your injury?
7. Did you take time off work due to your injury?
8. Brief details of injury/circumstances
9. Full Name
10. Email Address
11. Telephone Number
Please enter an accurate e-mail address and telephone number to receive your results.