CIC Online Application Form


Type of application *



Injured person details


Title *

First name *

Last name *

Previous names

Please provide details of any previous name(s) you may have used (e.g. maiden names)
Date of Birth *

Injured person's date of birth
Gender

MaleFemale

Injured person's gender
Address line 1 *

Address line 2

City/town

County

Postcode

Contact e-mail

Home phone number

Mobile phone number

Work phone number

Preferred contact method



Residency statements


Do you live in the United Kingdom? *

YesNo

This question must be answered

Incident details


What time and date did the incident occur?
Date of incident *

Time of incident


Do you know where the incident took place?


Incident address line 1

Incident address line 2

Incident city/town *

Incident county

Incident postcode

Please provide brief details of the incident *

This question must be answered


Country where the attack took place *

Were you and the assailant living together as members of the same family at the time of the attack?

YesNo

This question must be answered
What was the cause of your injuries *



Reporting details


Was the incident reported to the police?


When was the incident reported?
Date reported

Time reported


Name and address of the police station where the incident was reported
Name of police station

Police station address line 1

Police station address line 2

Police station city/town

Police station county

Police station postcode

Who reported the incident to the police

Name and ID number of the officer dealing with the incident?
Officer's name

Officer's ID number

Police crime reference number

Did the police take a statement? *

YesNo

Has the case gone to court? *

YesNoDon't know

If the assailant has been identified please confirm their name:



Injury details


Have you sought any medical treatment for your injuries? *

YesNo

What injuries did you receive? (please list up to 5 below)
1st injury *

2nd injury

3rd injury

4th injury

5th injury

Are you still receiving treatment? *

YesNo

What are your current symptoms?

If any of your injuries resulted in scarring where is it?

As a direct result of your injury, did you have no, or very limited, capacity for paid work for a period exceeding 28 weeks? *

YesNo

If you were off work when did you go back to work?



Medical details


It is important we have details of your GP even if you did not see them about the incident. Your GP will hold medical information which we may need to access.


GP details
Are you registered with a GP?

YesNo

Did you attend your GP in relation to this incident?

YesNo

GP attendance date (if attended)

GP or surgery name?

GP or surgery address line 1

GP or surgery address line 2

GP or surgery city/town

GP or surgery county

GP or surgery postcode



Accident & Emergency details
Did you go to Accident & Emergency?

Which hospital did you visit

Date of hospital visit?


Hospital details
Have you attended hospital for treatment?

Which hospital did you visit for treatment?

Have you had additional hospital visits to the one above?

YesNo


Dentist's details
Did you visit a dentists?

Dentist name or dental practice?

Date of your first visit to your dentist?

Dentist address line 1

Dentist address line 2

Dentist city/town

Dentist county

Dentist postcode


Other treatment
Did you visit any other treatment providers (e.g. physiotherapist)?

Please provide details of other treatment providers

Are you expecting to receive further treatments?

YesNo


Previous applications


Have you applied to the CICA for compensation for the same incident before? *

YesNo

Criminal convictions


Do you have any criminal convictions, including simple cautions and reprimands, in the UK or abroad? *


Country of offence

Offence

Sentence

Date of sentence

Any additional convictions, cautions or reprimands?

YesNo


Additional information


Please tell us anything else you think we need to know

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