Litigation Instruction Form – Employer Liability - Peter O’Connor & Son Solicitors LLP

Litigation Instruction Form – Employer Liability

Date*
DD slash MM slash YYYY
Name*
First Last
Source*
Date of birth*

Day
Month
Year
Status*
PPS number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home phone*
Mobile phone
Occupation description*
Accident date*
Accident time*

: hh

mm

AM/PM
Accident location*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of other party*
First Last
Respondent address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Was it reported?*
- Yes
- No
To whom was it reported*
Name of witness
First Last
Witness address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Injuries*
Doctor
First Last Hospital
Name of employer
First Last
Gross wages*
Net wages*
Time off work*
Circumstances of accident*

Date*
DD slash MM slash YYYY
Name*
First Last
Source*
Date of birth*
Status*
PPS number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home phone*
Mobile phone*
Occupation description*
Accident date*
Accident time*

: Hours

Minutes

AM/PM
Accident location*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer's name*
First Last
Respondent address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employment record*
Was accident reported*
- Yes
- No
To whom was the accident reported*
Name of witness*
First Last
Address of witness*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Injuries*
Doctor*
First Last
Hospital*
Net wages*
Gross wages*
Special damages*
Time off work*
Social welfare benefits*
Circumstances of accident*