Personal Injury Assistance Application Form

Your Details

Name:

Address:

Telephone number:

E-mail address:

Date of incident:

Brief details of the incident:

Has liability been admitted?:

Yes, by me

Yes, by the other party

Legal Proceedings

Have legal proceedings been issued?:

Yes

If so, in which court and on what date?:

Have legal proceedings occurred?:

Yes

If so, what was the outcome?:

Name and Address of your current solicitors:

Are you happy for CDF to contact your solicitors for information?:

Yes

Who is the defendent in your claim?:

Who are the defendent’s solicitors?:

Who are the defendent’s insurers?:

Funding

How is your case currently funded?:

e.g. conditional fee agreement, trade union or membership organisation funding, legal expenses, etc.

If financial assistance is needed, how much?:

Summary of the assistance you require from CDF:

What documents can you send that would support your application for assistance?:

Please note that we would usually expect to see:

If you are already represented by a Solicitor, copies of all documents relating to how your claim is presently funded
Copies of all Court Documents
Medical Evidence if your case relates to a claim for injuries
Correspondence – perhaps between you and your Solicitor or any other correspondence that is relevant to the issue that you are asking CDF to consider
A copy of any opinion that may have been obtained from a Barrister about your case

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