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Injury Compensation Claim Form

This online claim form is to be used by URTU members and their dependents, for the reporting of an accident which might give rise to a claim for damages for injuries and loss sustained from that accident.

The URTU Injury Compensation Scheme covers you if you have had an accident or contracted an industrial disease at work. It also includes accidents not connected with work (if the injury results in absence from work). Follow our advice and, win or lose, there will be no charge to you. If the claim should fail, the Union will indemnify you against any claim for costs made by the defendants or their insurers.

URTU has an outstanding record in handling these cases; winning compensation for hundreds of members each year. The type of incidents dealt with ranges from simple, minor cases like a sprained ankle to complex situations resulting in death.

URTU membership number:

Full Name:

Address:

Postcode:

Email:

Telephone Number:

Mobile Number:

Date of Accident: (leave blank if industrial disease contracted over time)

Occupation:

Name & Address of Employer:

Please select the type of accident that applies

Accident at work
Road traffic accident
Accident out of work
Industrial disease

If accident, where did it happen?

If disease, where contracted?

TERMS AND CONDITIONS OF THE PERSONAL INJURY SCHEME

The Rules of the Union apply.
A member making a claim for compensation must have been a member of the Union on the day preceding the date of the accident or, in the event of a claim for compensation for an industrial disease, a member of the Union when he contracted the disease. Unless the member dies, the member must remain a member until the claim is concluded.
Claims for compensation can only be accepted on the authority of the member, or a relative of a deceased member, or personal representative of the Estate of a deceased member, or next friend in the event of disability.
During the process of a claim, should the member (relative, next friend, or personal representative) fail to co-operate with, or fail to comply with the advice of the Union's Solicitors without the sanction of the Executive Committee or the General Secretary, support shall be withdrawn and the member (relative, representative or next friend) will be required to refund to the Union any costs and expenses that the Union may be liable for by way of legal assistance.
In the event of a claim failing, or support having to be withdrawn due to the deliberate false evidence, statement or statements of the member (relative, representative or next friend), whether written or verbal, whether in Court or not, the member, representative or next friend will repay to the Union any legal costs and expenses that the Union may have incurred by way of legal assistance and, for the avoidance of doubt, the Union will not indemnify the member (relative, representative or next friend) against any claim for costs by the opponents in the claim.
In the event of the member (relative, representative or next friend) terminating the legal retainer before the end of the case without the sanction of the Executive Committee or General Secretary, support shall be withdrawn.
I consent to the Union engaging the services of a Solicitor on the basis of a Collective Conditional Fee Agreement entered into between the Union and the Legal Representatives if the Union considers it appropriate.
I have read and fully understand the Conditions appertaining to the completion of this Application Form and agree to abide by them.
I believe that the information I have given in this Application Form is true to the best of my knowledge and belief.

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Injury Compensation Claim Form

TERMS AND CONDITIONS OF THE PERSONAL INJURY SCHEME

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