Industrial Disease Claim Form - British Coal (NCB)

1. Compensation Claim - Claim for Lump Sum Payment (£4,000 - £25,000)

You have been invited to complete this survey by Lucy, upon completion you will receive a review of your case and she will be in touch to discuss your claim for compensation.

1. 1. Your Contact Details:

First Name:
Last Name:
Address:
Town:
Postcode:
Telephone Number:
National Insurance Number:
Email Address:
Date of Birth:
Name of GP:

2. 2. 1. What injuries are you looking to claim for?

Hearing Loss

3. 3. 2. Have you previously claimed, or received any advice?

Yes, I had a hearing test only and was turned down on the day of the test
No, i have not claimed previously
Yes, I have been Paid Out

4. 3. Have you been a member of the armed forces?

Yes
No

5. 4. National Coal Board Details:

Name Of Colliery:
What years did you work from and till:
What machines/ Tools did you operate

6. Due to the on going pandemic our staff is working remotley and our call facility is really busy during this time. Our panel of solicitors operate on a NO Win No Fee Basis so you will not be charged throughout the entire process of the claim.

How we get paid?
We take a 25% from the figure you receive. If you are happy to proceed please submit the information and you will receive a claim pack in the post in the next 2-3 days.

I am Happy with the Deduction of 25%.. I Understand the claim is No Win No Fee and happy to proceed

We collect and use your personal information in order for us to provide you with our Claims Managementservice. That is, to identify whether you have a claim and put you in contact with an appropriate legal services provider that we recommend.We may use your personal information to send marketing communications to you about similar claimservices that may be of interest to you. We will send our marketing communications to you by email. You can object to your personal information being used by us to send you marketing information. Each marketing email will also include an unsubscribe link to enable you to opt-out of receiving future marketing communications.