CICA Personal Injury Claim Form

Abuse and assault extended enquiry form

Your Story - Your Experiences

My story of abuse and neglect
17/06/2018        Anonymous

Abused by family members and friend
06/12/2017        Anonymous

My rape story
05/12/2017        Anonymous

More stories

Tell us more about your case

Please complete our form below to provide more detail about your circumstances. We will immediately assess your potential claim and advise whether you have a case.

First Name(s)
Your Address
Primary contact phone number
Is your contact number home, mobile or work?
Additional contact phone number
If you have any additional contact numbers, feel free provide them

Is your secondary contact number home, mobile or work?
Email Address