PERSONAL INJURY OR DISEASE COMPENSATION CLAIM (TU56)

BEFORE APPLYING TO THE GMB FOR LEGAL ASSISTANCE IN MAKING A CLAIM FOR COMPENSATION, PLEASE READ THE FOLLOWING UNDERTAKINGS CAREFULLY.

THIS FORM WILL BE E-MAILED DIRECTLY TO SYLVA KLOJDOVA IN THE LEGAL DEPARTMENT. IF YOU DO NOT GET AN ANSWER WITHIN 28 DAYS, PLEASE CONTACT SYLVA AT THE REGIONAL OFFICE.

THERE IS USUALLY A THREE YEAR TIME LIMIT FOR MAKING CLAIMS, HOWEVER IF YOU ARE IN ANY DOUBT PLEASE CONTACT THE LEGAL DEPARTMENT.

1. I apply to the GMB for legal assistance in making a claim for compensation. I confirm that there is no solicitor acting for me. I understand that the Union will decide whether to provide legal assistance according to the rules. If legal assistance is granted, I authorise the Union to nominate a solicitor to act on my behalf.
2. I also understand that even though I will be formally liable for legal costs incurred as a result of my claim (as solicitors' clients normally are), the Union will indemnify me i.e. will pay all legal costs incurred for me, provided that I satisfy the conditions of the Union's legal assistance scheme.
3. Those conditions are:

• I must remain a member of the Union and continue to pay my correct GMB contributions during the course of my claim.
• I must accept and act on the advice of the solicitor nominated to act for me.
• I must co-operate with the solicitor, and in particular reply to correspondence, attend arranged appointments, provide them as far as I can with all relevant information, and inform them of any change of address or name.

If I fail to comply with any such condition, or if I wilfully provide false information to the Union or the solicitor nominated to act for me or to any doctor, engineer or other expert concerned in the claim, whether on the application form for legal assistance or otherwise, the Union will have the right to withdraw legal assistance. In the event, I will not be entitled to any indemnity for my liability for costs incurred in the course of my claim, and the Union shall be entitled to recover from me any costs already incurred by the Union.

4. I authorise the Union and the solicitor nominated to act for me to withhold compensation recovered for me until I have paid any cost, arrears of contributions, that may be due from me.

Please tick the box to confirm you accept the GMB Union terms and conditions.

SECTION 1 - MEMBER'S DETAILS

Surname

First Name

GMB Membership No

Home Address

Day Time Telephone Number

Email Address of Member

SECTION 2 - CLAIMANT'S DETAILS IF DIFFERENT FROM MEMBER

Surname

First Name

Home Address

Day Time Contact Telephone Number

Preferred Email Address

Relationship to Member

SECTION 3 - ACCIDENT OR DISEASE DETAILS

Date of Accident

SECTION 4 - DETAILS OF THE CAUSE OF THE ACCIDENT
In this section you need to express as clearly and briefly as possible the events that lead to the accident, including where it happened and what you were doing at the time. If it is a disease, give information of any substances or work process you consider responsible. You must remember that the person reviewing your case will have no prior knowledge of your job, place or processes of work. Therefore, if you can give greater detail this will assist the person in assessing your claim. You may be asked to provide at a later date, a diagram, sketch or photographic evidence of the scene of the accident.

Describe your injuries or symptoms of disease

Please type this into the box

You must print a copy of this form for your own reference, click on the printer button at the top of the page or alternatively go to File, and Print. You can additionally save a copy onto your computer by going to File, Save As and then selecting a folder and file name.

This form is sent via your email address which must be typed in the Email Address of Member box.