{"id":1686,"date":"2026-09-15T21:39:24","date_gmt":"2026-09-15T21:39:24","guid":{"rendered":"https:\/\/www.injurycheck.info\/?page_id=1686"},"modified":"2026-09-30T19:18:11","modified_gmt":"2026-09-30T09:18:11","slug":"claims-enquiry-form","status":"publish","type":"page","link":"https:\/\/www.injurycheck.info\/pa\/claims-enquiry-form\/","title":{"rendered":"Claims Initial Enquiry Form \u2013 get answers within 24 hours"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"1686\" class=\"elementor elementor-1686\">\n\t\t\t\t<div class=\"has_eae_slider elementor-element elementor-element-93d8828 e-flex e-con-boxed e-con e-parent\" data-eae-slider=\"55470\" data-id=\"93d8828\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eb9b704 elementor-widget elementor-widget-elementskit-contact-form7\" data-id=\"eb9b704\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-contact-form7.default\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" ><div class=\"ekit-form\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1687-p1686-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"1687\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/pa\/claims-enquiry-form\/#wpcf7-f1687-p1686-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"\u0a38\u0a70\u0a2a\u0a30\u0a15 \u0a2b\u0a3e\u0a30\u0a2e\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/claims-enquiry-form\/#wpcf7-f1687-p1686-o1\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1687\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.7\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1687-p1686-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"1686\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p><strong>Claims Initial Enquiry<\/strong>\n<\/p>\n<p>We\u2019ll get answers within 24 hours.\n<\/p>\n<p>Fill in all the details you are comfortable with. Only your name, phone and email are required. The more information you provide, the quicker we can assess whether you have a claim for compensation.\n<\/p>\n<h3>Client Details\n<\/h3>\n<p><label><em>Full Name<\/em> (required) <span class=\"wpcf7-form-control-wrap\" data-name=\"full-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"full-name\" \/><\/span><\/label><label><em>DOI (Date of Incident)<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"date-of-incident\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-of-incident\" \/><\/span><\/label><label><em>DOB<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"date-of-birth\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-of-birth\" \/><\/span><\/label><label><em>\u0a2a\u0a24\u0a3e<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"address\" \/><\/span><\/label><label><em>Phone<\/em> (required) <span class=\"wpcf7-form-control-wrap\" data-name=\"phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"phone\" \/><\/span><\/label><label><em>\u0a08\u0a2e\u0a47\u0a32<\/em> (required) <span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span><\/label><label><em>Employer at time<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"employer-at-time\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employer-at-time\" \/><\/span><\/label><label><em>Employed as<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"employed-as\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employed-as\" \/><\/span><\/label><label><em>Injuries<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"injuries\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"injuries\"><\/textarea><\/span><\/label><label><em>Previous injuries<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"previous-injuries\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"previous-injuries\"><\/textarea><\/span><\/label>\n<\/p>\n<h3>Medical\n<\/h3>\n<p><label><em>Doctors<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"doctors\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"doctors\"><\/textarea><\/span><\/label><label><em>Physiotherapists<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"physiotherapists\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"physiotherapists\"><\/textarea><\/span><\/label><label><em>Specialists<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"specialists\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"specialists\"><\/textarea><\/span><\/label>\n<\/p>\n<h3>TPD if applicable\n<\/h3>\n<p><label><em>Super fund<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"super-fund\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"super-fund\" \/><\/span><\/label><label><em>TPD amount<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"tpd-amount\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"tpd-amount\" \/><\/span><\/label><label><em>Policy number<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"policy-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"policy-number\" \/><\/span><\/label>\n<\/p>\n<h3>MVA\n<\/h3>\n<p><label><em>Police report number<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"police-report-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"police-report-number\" \/><\/span><\/label>\n<\/p>\n<p><em>Collision type<\/em>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"mva-type\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"mva-type[]\" value=\"Vehicle vs Vehicle\/Motorcycle\" \/><span class=\"wpcf7-list-item-label\">Vehicle vs Vehicle\/Motorcycle<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"mva-type[]\" value=\"vs Bicycle\" \/><span class=\"wpcf7-list-item-label\">vs Bicycle<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"mva-type[]\" value=\"vs Pedestrian\" \/><span class=\"wpcf7-list-item-label\">vs Pedestrian<\/span><\/label><\/span><\/span><\/span><label><em>Rego 1<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"rego-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rego-1\" \/><\/span><\/label><label><em>Rego 2<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"rego-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rego-2\" \/><\/span><\/label><label><em>WorkCover claim number<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"workcover-claim-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"workcover-claim-number\" \/><\/span><\/label><label><em>Ombudsman reports for med neg<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"ombudsman-reports\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"ombudsman-reports\"><\/textarea><\/span><\/label>\n<\/p>\n<h3>Evidence\n<\/h3>\n<p><em>Doctors reports available?<\/em>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"doctors-reports\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"doctors-reports\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"doctors-reports\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><label><em>Photos of incident\/injuries<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"incident-photos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.png,.pdf\" aria-invalid=\"false\" type=\"file\" name=\"incident-photos\" \/><\/span><\/label>\n<\/p>\n<p>If file upload is not available, please note whether photos are available below.\n<\/p>\n<p><label><em>Photos available (yes\/no) and note<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"photos-note\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"photos-note\"><\/textarea><\/span><\/label>\n<\/p>\n<h3>Additional\n<\/h3>\n<p><em>Currently with a lawyer?<\/em>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"currently-with-lawyer\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"currently-with-lawyer\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"currently-with-lawyer\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><label><em>Current issues with law firm\/lawyer<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"current-lawyer-issues\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"current-lawyer-issues\"><\/textarea><\/span><\/label><label><em>How previous injuries affected you prior to this incident<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"previous-injuries-impact\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"previous-injuries-impact\"><\/textarea><\/span><\/label>\n<\/p>\n<h3>Liability\n<\/h3>\n<p><label><em>How injury occurred<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"how-injury-occurred\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"how-injury-occurred\"><\/textarea><\/span><\/label>\n<\/p>\n<p><em>Liability type<\/em>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"liability-type\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"liability-type[]\" value=\"Medical negligence\" \/><span class=\"wpcf7-list-item-label\">Medical negligence<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"liability-type[]\" value=\"At Work\" \/><span class=\"wpcf7-list-item-label\">At Work<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"liability-type[]\" value=\"Motor Vehicle\" \/><span class=\"wpcf7-list-item-label\">Motor Vehicle<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"liability-type[]\" value=\"Public Liability\" \/><span class=\"wpcf7-list-item-label\">Public Liability<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"liability-type[]\" value=\"Rental Property Injury\" \/><span class=\"wpcf7-list-item-label\">Rental Property Injury<\/span><\/label><\/span><\/span><\/span><label><em>Further answer<\/em> <span class=\"wpcf7-form-control-wrap\" data-name=\"liability-further-answer\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"liability-further-answer\"><\/textarea><\/span><\/label>\n<\/p>\n<div class=\"ic-consent\" style=\"color:#222;\">\n\t<p class=\"ic-consent-notice\"><strong>Before you send<\/strong>\n\t<\/p>\n\t<p>Injury Check is not a law firm. We use your details to check whether you may have a claim and, if you agree, to send them to the law firm you choose so it can contact you. Some of our service providers store data overseas, including in the United States. You can access, correct or delete your information at any time: <a href=\"mailto:info@injurycheck.info\">info@injurycheck.info<\/a>. <a href=\"https:\/\/www.injurycheck.info\/pa\/privacy-policy\/\" target=\"_blank\" rel=\"noopener\">Read our Privacy Policy<\/a>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"consent-health\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"consent-health\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I agree to Injury Check collecting my injury and health information and any photos or documents I provide, to check my claim, as described in the <a href=\"https:\/\/www.injurycheck.info\/pa\/privacy-policy\/\" target=\"_blank\" rel=\"noopener\">\u0a2a\u0a30\u0a3e\u0a08\u0a35\u0a47\u0a38\u0a40 \u0a2a\u0a3e\u0a32\u0a3f\u0a38\u0a40<\/a>.<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"consent-referral\"><span class=\"wpcf7-form-control wpcf7-acceptance optional\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"consent-referral\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I agree to Injury Check sending my details, including my health information and photos, to the law firm the injured person chooses so it can contact me.<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<input class=\"wpcf7-form-control wpcf7-hidden\" value=\"\" type=\"hidden\" name=\"referral_code\" \/>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit enquiry\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>\u0a21\u0a48\u0a32\u0a1f\u0a3e<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"238\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<input type=\"hidden\" name=\"trp-form-language\" value=\"pa\"\/><\/form>\n<\/div>\n<\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Claims Initial Enquiry We\u2019ll get answers within 24 hours. Fill in all the details you are comfortable with. Only your name, phone and email are required. The more information you provide, the quicker we can assess whether you have a claim for compensation. Client Details Full Name (required) DOI (Date of Incident) DOB Address Phone [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"content-type":"","footnotes":""},"class_list":["post-1686","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.injurycheck.info\/pa\/wp-json\/wp\/v2\/pages\/1686","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.injurycheck.info\/pa\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.injurycheck.info\/pa\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.injurycheck.info\/pa\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.injurycheck.info\/pa\/wp-json\/wp\/v2\/comments?post=1686"}],"version-history":[{"count":10,"href":"https:\/\/www.injurycheck.info\/pa\/wp-json\/wp\/v2\/pages\/1686\/revisions"}],"predecessor-version":[{"id":1837,"href":"https:\/\/www.injurycheck.info\/pa\/wp-json\/wp\/v2\/pages\/1686\/revisions\/1837"}],"wp:attachment":[{"href":"https:\/\/www.injurycheck.info\/pa\/wp-json\/wp\/v2\/media?parent=1686"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}