Please select...I am applying for a single incidentI am applying for a period of abuseI am applying because someone has died
Injured persons titleMasterMrMrsMissMsDr
Preferred contact methodE-mailHome phoneMobile phoneWork phone
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Please select...Accident (trip/fall)Animal attack (no intent to injure)Animal attack (with intent to injure)Assault using a weaponAssaultAttempted suicideDomestic/family violenceInjury due to arsonInjury sustained in utero through the ingestion of harmful substancesPoisoningSexual assaultSporting injurySuicideTrespass on road or railwayUse of vehicle (no intent to injure)Use of vehicle (with intent to injure)Witnessed the incident