Gympie

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2. Contact Email
3. Contact Email Secondary
4. Enquiry Title
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6. Contact Type
7. Referrer
8. Full name
9. Phone
12. Email
13. Postcode
14. Legal issue
15. Vic Qld Public Liability
16. Vic Work
17. Vic Road
18. Qld Road
19. Can you briefly describe your injury?
20. Details
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• Vic Qld Public Liability
• Vic Work
• Vic Road
• Qld Road

Contact Email

Contact Email Secondary

Enquiry Title

stateIdentify

Contact Type

Referrer

Full name

Phone

Email

Postcode

Legal issue

Please select Asbestos or silica diseases Childhood abuse Class actions Compensation claims Employment issues Financial advice disputes Insurance claims or disputes Medical negligence claims Psychological injuries Public place injuries Road injuries Social justice Superannuation claims TPD claims Wills & estates Work injuries Workplace diseases Other

Do you recall the date of the accident?

Yes

I can’t remember 

Have you had time off work or has your work been impacted because of your injury?

Yes

No

How did the injury occur and was it someone else’s fault?

When did the injury/illness/accident occur?

Has your WorkCover claim been accepted?

Yes

No

No claim logged

Decision pending

Do you recall the date of the accident?

Yes

I can’t remember 

Has your TAC claim been accepted?

Yes

No

No claim logged

Decision pending

Do you recall the date of the accident?

Yes

I can’t remember 

What was the cause of the accident?

Can you briefly describe your injury?

Details

Terms and conditions

I agree to Maurice Blackburn collecting this information and getting in contact with me in accordance with the Collection Statement and Privacy Policy

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Web User ID