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Online Claim Form - Public or Private Place

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Lodge your Claim Online

We have made it easier for clients to give all information accurately so that we can open up your compensation claim efficiently. This form is for any incidents on at a public or private premise.

By submitting your online claim, you agree to the Privacy Policy which can be found here.

Personal Details
Accident Details 1
Accident Details 2
Injuries
Declaration

Name

Surname

Given Name(s)

Address

Home Address

Postal Address

Contact Methods

Contact Number

Email Address

Date Of Birth

Date of Birth

Interpreter

Language

Date and Time

Date

Time

Incident Report

Name of Person to whom incident reported

Address

Phone Number

Other Parties Involved

Please provide as much information as you can

Location of the Accident

Location

Description of the Accident

Describe how the accident happened

Did Police Attend the Accident

Please Select

If so, what is the Event Number

Did you attend Hospital

Please Select

If so, which Hospital

Your Treating Doctor

Doctor’s Name

Address of Doctor’s Practice

What injuries have you sustained as a result of the incident?

Injuries sustained

What are your continuing disabilities

Disabilities

What is your occupation

Occupation

What is your weekly net income?

Income

How long have you been off work since the incident

Time

Have you returned to work

Please select

Have you had any prior injuries or claims

Please select

If so, please provide details

Please confirm you have read the Privacy Policy

Please select

Please confirm you have read the Privacy Policy

Please tick

Yes

Please confirm that all information you have given in the claim form must be true and correct in every respect

Please tick

Yes

Theresa Tran

5
5/5
3 months ago
Phuong and the team at Alliance were attentive to our needs and efficient in providing legal services. I’d highly recommend their team!
Andy Scanlan

5
5/5
10 months ago
A big thank you to John and his team. Appreciate the support and dedication they gave me. I highly recommend their services.
Bo

5
5/5
11 months ago
John and phoung were able to help me look over my contract for a home loan in record time. I was on a short deadline and they were so accommodating to help. I had the whole process done in less than 24 hours. Really appreciate all their help and could not recommend them enough!
Trien Cong

5
5/5
3 months ago
I would like to recommend lawyer John and his staffs to anyone that need help from a work injury or a car accident. Lawyer John and his lawyer Katherine are very helpful and professional. They will give you the right advice what you need to claim for your injury. And believe me, you will get what you want. Once again, a big thanks to John and his team.
Van Le

5
5/5
10 months ago
A few years ago, I was injured and could no longer work. I didn’t know that I could dip into my superannuation for super and income protection claims, but a friend referred me to Alliance team. Best decision I ever made! They were so helpful and professional. Their fees were a reasonable price for what they have to do for you. The amount of money they claimed alleviated my financial hardship and provided financial stability during the time we needed it most. I would highly recommend Alliance l... Read More
A few years ago, I was injured and could no longer work. I didn’t know that I could dip into my superannuation for super and income protection claims, but a friend referred me to Alliance team. Best decision I ever made! They were so helpful and professional. Their fees were a reasonable price for what they have to do for you. The amount of money they claimed alleviated my financial hardship and provided financial stability during the time we needed it most. I would highly recommend Alliance lawyers to anyone that needs help with their claims. Thank you to John Truong and staff for all the help. Read Less

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Online Claim Form - Public or Private Place

stay connected

Lodge your Claim Online

Personal Details

Accident Details 1

Accident Details 2

Injuries

Declaration

Name

Surname

Given Name(s)

Address

Home Address

Postal Address

Contact Methods

Contact Number

Email Address

Date Of Birth

Date of Birth

Interpreter

Language

Date and Time

Date

Time

Incident Report

Name of Person to whom incident reported

Address

Phone Number

Other Parties Involved

Please provide as much information as you can

Location of the Accident

Location

Description of the Accident

Describe how the accident happened

Did Police Attend the Accident

Please Select

If so, what is the Event Number

Did you attend Hospital

Please Select

If so, which Hospital

Your Treating Doctor

Doctor’s Name

Address of Doctor’s Practice

What injuries have you sustained as a result of the incident?

Injuries sustained

What are your continuing disabilities

Disabilities

What is your occupation

Occupation

What is your weekly net income?

Income

How long have you been off work since the incident

Time

Have you returned to work

Please select

Have you had any prior injuries or claims

Please select

If so, please provide details

Please confirm you have read the Privacy Policy

Please select

Please confirm you have read the Privacy Policy

Please tick

Please confirm that all information you have given in the claim form must be true and correct in every respect

Please tick

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