CIC Online Application Form

Type of application *

Address line 1 *

Home phone number

Mobile phone number

Work phone number

Preferred contact method

Residency statements

Do you live in the United Kingdom? *

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 *

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?

What was the cause of your injuries *

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? *

If the assailant has been identified please confirm their name:

Have you sought any medical treatment for your injuries? *

What injuries did you receive? (please list up to 5 below)

Are you still receiving treatment? *

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? *

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

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.

Are you registered with a GP?

Did you attend your GP in relation to this incident?

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

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

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

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

Please tell us anything else you think we need to know

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Injured person details

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Reporting details

Injury details

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