CICA Personal Injury Claim Form

Abuse and assault extended enquiry form

    Or to provide more detail – If preferred complete our extended CICA application form.

    You can read our privacy policy here confirming how we manage and protect your data.

    Important information for you

    Your Story - Your Experiences

    Raped by so called friends
    03/01/2021        Dee

    my uncle sexually touched me
    06/11/2020        Anonymous

    Hammer attack
    30/10/2020        EH

    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.

      Title
      First Name(s)
      Surname
      Your Address
      Postcode
      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
      Date of birth
      Town of birth
      Marital Status
      Occupation
      Do you have any previous criminal convictions?
      If yes, please provide more details and include dates of any known convictions - IMPORTANT
      Have you made a previous application to the CICA in relation to this particular incident?
      Please provide your GP details practice address
      Did you visit your GP about the incident(s)? If so on what date (approximate date is fine)?
      Please list the injuries or psychological symptoms caused by the incident(s)
      Describe more about the impact of the event(s) on you personally. Ie: on your life, work, relationships etc
      Have you been or are you expected to be unable to work for 28 weeks or more?
      Date of incident (if known)
      Approximate time if relevant
      Please describe clearly what happened
      Exact place of the incident
      Name of person(s) responsible for your injuries (if known)
      State whether this person / these individuals are known to you.
      Did you report the matter to the police?
      Date of report (approximate date fine)
      Time of report (if relevant)
      Police Authority (Area)
      Police branch address
      Full address including post code Crime reference or police office in charge if known (IMPORTANT)
      Did you make a formal police statement?
      Have you attended court?
      If yes, please provide the court date
      If you have not attended court, please explain why
      I believe that the facts stated in this questionnaire are true and accurate to the best of my knowledge. By pressing the SEND button below you are sending this form directly to the Criminal Claims Bureau. Your data is confidential and is protected, we do not share your personal details with any other body. The person who will be handling your claim will contact you shortly.
      Declaration
      Criminal Injuries

      01423 593 002

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      The Criminal Claims Bureau is a trading name of MJN Marketing Ltd a claims management company registered in England and Wales registration number 04772563 authorised & regulated by the Financial Conduct Authority. (Reference Number: 829747)