in legal: Employment tribunals; Personal injury - work-related and non-work-related; Claiming state benefits - work related; Free will service; Low cost conveyancing; Half an hour’s free legal advice; Medical negligence

Online personal injury claim form

Section 1: Member's details

Surname:*
First name:*
GMB Membership No:*
Date of birth:
Gender:: Male Female
Home address:*
Address 2:
Town:*
Postcode:*
Home telephone:
Work telephone:
Mobile:
Email address of member:*
Employers name:
Employers address:
Address2:
Town:
Postcode:

Section 2: Claimant's details if different from member

Surname:
First name:
Date of birth:
Gender:: Male Female
Home address:
Address2:
Town:
Postcode:
Home telephone:
Work telephone:
Mobile:
Email address:
Relationship to member:

Section 3: Accident or disease details

Date of Accident:
Date of onset of Disease:

Section 4: Details of the cause of the accident/disease

Please describe the circumstances of the accident, including where it happened and what you were doing at the time.
If it is a disease, please provide details of the substances or work process you consider responsible.

Section 5: Disease symptoms or injuries

Please describe your injuries or symptoms of disease.

Before applying to the GMB for legal assistance in making a claim for compensation, please read the following undertakings carefully. There is usually a three year time limit for making claims. However if you are in any doubt please contact the legal department on 0115 9601112.

I apply to the GMB for legal assistance in making a claim for compensation. I confirm there is no other solicitor acting for me. I understand the union will decide whether to provide legal assistance according to the rules. If legal assistance is granted, I authorise the Union to nominate a solicitor to act on my behalf.
I also understand that even though I will be formally liable for legal costs incurred as a result of my claim (as solicitors' clients normally are), the Union will pay all legal costs incurred, provided I satisfy the conditions of the Union's legal assistance scheme.
Those conditions are:
- I must remain a member of the Union and continue to pay my GMB contributions during the course of my claim.
- I must accept and act on the advice of the solicitor nominated to act for me.
- I must co-operate with the solicitors, and in particular reply to correspondence, attend arranged appointments, provide them as far as I can with all relevant information and inform them of any change of address or name.
If I fail to comply with any of these conditions, or if I wilfully provide false information to the Union or the solicitor or to any expert concerned in the claim, the Union will have the right to withdraw legal assistance. In this situation, I will not be entitled to any indemnity for my liability for costs incurred in the course of my claim, and the union will be entitled to recover from me any costs already incurred by the Union.
I authorise the Union and the solicitor nominated to act for me to withhold compensation recovered for me until I have paid any costs or arrears of contributions that may be due from me.

Please make sure your contact details are correct so that we can get in touch with you.

This form will be emailed directly to Karen Roache in the legal department. If you do not get an answer within 7 days, please contact the legal department on 0115 9601112