"*" indicates required fields

Step 1 of 3

This questionnaire contains three parts, (1) the client details (if applicable), (2) the passengers details and (3) the passenger's injries.

Client Details

This section is devoted to details about the Client – where the client IS NOT the passenger due to the passenger either being (A) Deceased or (B) Incapacitated and/or unable to represent their own interests – as in the case of a minor.

In the event that the passenger is able to represent the interests of his or herself – proceed to the next section by clicking the NEXT button at the end of the form.

Client's Name
Client's Date of Birth
Client's Address