apply-public-injury.claim-mate.com
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45.63.29.1
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URL:
https://apply-public-injury.claim-mate.com/
Submission: On August 10 via automatic, source certstream-suspicious — Scanned from AU
Submission: On August 10 via automatic, source certstream-suspicious — Scanned from AU
Form analysis 1 forms found in the DOM
POST #
<form action="#" class="form" id="form" method="post" autocomplete="on" novalidate="novalidate">
<input type="hidden" name="campaign_post_key" value="YTMQw5B3pJzPlXubymigaFt2c">
<div id="step1" class=" form-step step-item">
<h2 class="step_heading">Have you been injured in a public place?</h2>
<div class="hero-form mt-4">
<div class="row form-fill">
<div class="col-md-12">
<input type="radio" id="injury1" value="Yes" name="injury" data-format="radio" class="option-radio ">
<label for="injury1" class="btn btn-block btn-radio hvr-grow injury1" id="select-option">Yes</label>
</div>
<div class="col-md-12">
<input type="radio" id="injury2" value="No" name="injury" data-format="radio" class="option-radio ">
<label for="injury2" class="btn btn-block btn-radio hvr-grow injury2" id="select-option">No</label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div id="address-text" style="text-align: center;"></div>
<div class="row step1">
<!-- NEXT | SUBMIT -->
<div class="col-12">
</div>
</div>
</div>
</div>
<div class="form-footer mt-3">
<p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
</div>
</div>
<div id="step2" class="d-none form-step step-item">
<h2 class="step_heading">In which state did the accident occur?</h2>
<div class="hero-form mt-4">
<div class="row form-fill">
<div class="col-md-12">
<div class="input-box py-2">
<select name="incident_location" id="incident_location" class="form-control form-custom custom-select " required="required" aria-required="true">
<option value="" selected="" disabled="" hidden=""></option>
<option value="Queensland">Queensland</option>
<option value="New South Wales">New South Wales</option>
<option value="Victoria">Victoria</option>
<option value="Australian Capital Territory">Australian Capital Territory</option>
<option value="Western Australia">Western Australia</option>
<option value="Tasmania">Tasmania</option>
<option value="South Australia">South Australia</option>
<option value="Northern Territory">Northern Territory</option>
<option value="Outside of Australia">Outside of Australia</option>
</select>
<label for=" incident_location">Select your State</label>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div id="address-text" style="text-align: center;"></div>
<div class="row step2">
<!-- Back Button -->
<div class="col-6">
<a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
</div>
<!-- NEXT | SUBMIT -->
<div class="col-6">
<button type="button" class="next-link float-right">Next </button>
</div>
</div>
</div>
</div>
<div class="form-footer mt-3">
<p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
</div>
</div>
<div id="step3" class="d-none form-step step-item">
<h2 class="step_heading">How long ago did the accident occur? </h2>
<div class="hero-form mt-4">
<div class="row form-fill">
<div class="col-md-6">
<input type="radio" id="when_accident_occured1" value="1 year or less" name="when_accident_occured" data-format="radio" class="option-radio ">
<label for="when_accident_occured1" class="btn btn-block btn-radio hvr-grow when_accident_occured1" id="select-option">1 year or less</label>
</div>
<div class="col-md-6">
<input type="radio" id="when_accident_occured2" value="1 year or more" name="when_accident_occured" data-format="radio" class="option-radio ">
<label for="when_accident_occured2" class="btn btn-block btn-radio hvr-grow when_accident_occured2" id="select-option">1 year or more</label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div id="address-text" style="text-align: center;"></div>
<div class="row step3">
<!-- Back Button -->
<div class="col-6">
<a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
</div>
<!-- NEXT | SUBMIT -->
<div class="col-6">
</div>
</div>
</div>
</div>
<div class="form-footer mt-3">
<p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
</div>
</div>
<div id="step4" class="d-none form-step step-item">
<h2 class="step_heading">As a result of the accident, did any of the following occur?</h2>
<h4 class="text-center my-3 head_multiple"><i>Can select multiple answers</i></h4>
<div class="hero-form mt-4">
<div class="row form-fill">
<div class="col-md-6">
<input type="checkbox" id="accident_type1" value="Loss of life" name="accident_type_item[]" data-format="checkbox" class="option-radio ">
<label for="accident_type1" class="btn btn-block btn-checkbox hvr-grow accident_type1" id="select-option">Loss of life</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="accident_type2" value="Physical injury" name="accident_type_item[]" data-format="checkbox" class="option-radio ">
<label for="accident_type2" class="btn btn-block btn-checkbox hvr-grow accident_type2" id="select-option">Physical injury</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="accident_type3" value="Psychological injury" name="accident_type_item[]" data-format="checkbox" class="option-radio ">
<label for="accident_type3" class="btn btn-block btn-checkbox hvr-grow accident_type3" id="select-option">Psychological injury</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="accident_type4" value="Other" name="accident_type_item[]" data-format="checkbox" class="option-radio ">
<label for="accident_type4" class="btn btn-block btn-checkbox hvr-grow accident_type4" id="select-option">Other</label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div id="address-text" style="text-align: center;"></div>
<div class="row step4">
<!-- Back Button -->
<div class="col-6">
<a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
</div>
<!-- NEXT | SUBMIT -->
<div class="col-6">
<button type="button" class="next-link float-right">Next </button>
</div>
</div>
</div>
</div>
<div class="form-footer mt-3">
<p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
</div>
</div>
<div id="step5" class="d-none form-step step-item">
<h2 class="step_heading">What type of medical attention have you sought due to the injury or illness cause by the accident?</h2>
<h4 class="text-center my-3 head_multiple"><i>Can select multiple answers</i></h4>
<div class="hero-form mt-4">
<div class="row form-fill">
<div class="col-md-6">
<input type="checkbox" id="medication_attention1" value="Physiotherapy" name="medication_attention_item[]" data-format="checkbox" class="option-radio ">
<label for="medication_attention1" class="btn btn-block btn-checkbox hvr-grow medication_attention1" id="select-option">Physiotherapy</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="medication_attention2" value="Surgery" name="medication_attention_item[]" data-format="checkbox" class="option-radio ">
<label for="medication_attention2" class="btn btn-block btn-checkbox hvr-grow medication_attention2" id="select-option">Surgery</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="medication_attention3" value="General Practice" name="medication_attention_item[]" data-format="checkbox" class="option-radio ">
<label for="medication_attention3" class="btn btn-block btn-checkbox hvr-grow medication_attention3" id="select-option">General Practice</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="medication_attention4" value="Occupational Therapy" name="medication_attention_item[]" data-format="checkbox" class="option-radio ">
<label for="medication_attention4" class="btn btn-block btn-checkbox hvr-grow medication_attention4" id="select-option">Occupational Therapy</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="medication_attention5" value="Other" name="medication_attention_item[]" data-format="checkbox" class="option-radio ">
<label for="medication_attention5" class="btn btn-block btn-checkbox hvr-grow medication_attention5" id="select-option">Other</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="medication_attention6" value="None" name="medication_attention_item[]" data-format="checkbox" class="option-radio ">
<label for="medication_attention6" class="btn btn-block btn-checkbox hvr-grow medication_attention6" id="select-option">None</label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div id="address-text" style="text-align: center;"></div>
<div class="row step5">
<!-- Back Button -->
<div class="col-6">
<a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
</div>
<!-- NEXT | SUBMIT -->
<div class="col-6">
<button type="button" class="next-link float-right">Next </button>
</div>
</div>
</div>
</div>
<div class="form-footer mt-3">
<p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
</div>
</div>
<div id="step6" class="d-none form-step step-item">
<h2 class="step_heading">What type of injuries were sustained because of the accident?</h2>
<h4 class="text-center my-3 head_multiple"><i>Can select multiple answers</i></h4>
<div class="hero-form mt-4">
<div class="row form-fill">
<div class="col-md-6">
<input type="checkbox" id="type_of_injury1" value="Back or neck injury" name="type_of_injury_item[]" data-format="checkbox" class="option-radio ">
<label for="type_of_injury1" class="btn btn-block btn-checkbox hvr-grow type_of_injury1" id="select-option">Back or neck injury</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="type_of_injury2" value="Hip, knee, or ankle injury" name="type_of_injury_item[]" data-format="checkbox" class="option-radio ">
<label for="type_of_injury2" class="btn btn-block btn-checkbox hvr-grow type_of_injury2" id="select-option">Hip, knee, or ankle injury</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="type_of_injury3" value="Shoulder, elbow, or wrist injury" name="type_of_injury_item[]" data-format="checkbox" class="option-radio ">
<label for="type_of_injury3" class="btn btn-block btn-checkbox hvr-grow type_of_injury3" id="select-option">Shoulder, elbow, or wrist injury</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="type_of_injury4" value="Amputation of a leg, foot or hand" name="type_of_injury_item[]" data-format="checkbox" class="option-radio ">
<label for="type_of_injury4" class="btn btn-block btn-checkbox hvr-grow type_of_injury4" id="select-option">Amputation of a leg, foot or hand</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="type_of_injury5" value="Paraplegia or Quadriplegia Injury" name="type_of_injury_item[]" data-format="checkbox" class="option-radio ">
<label for="type_of_injury5" class="btn btn-block btn-checkbox hvr-grow type_of_injury5" id="select-option">Paraplegia or Quadriplegia Injury</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="type_of_injury8" value="Psychological illness or injury" name="type_of_injury_item[]" data-format="checkbox" class="option-radio ">
<label for="type_of_injury8" class="btn btn-block btn-checkbox hvr-grow type_of_injury8" id="select-option">Psychological illness or injury</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="type_of_injury6" value="Head injury" name="type_of_injury_item[]" data-format="checkbox" class="option-radio ">
<label for="type_of_injury6" class="btn btn-block btn-checkbox hvr-grow type_of_injury6" id="select-option">Head injury</label>
</div>
<div class="col-md-6">
<input type="checkbox" id="type_of_injury7" value="Loss of vision or hearing" name="type_of_injury_item[]" data-format="checkbox" class="option-radio ">
<label for="type_of_injury7" class="btn btn-block btn-checkbox hvr-grow type_of_injury7" id="select-option">Loss of vision or hearing</label>
</div>
<div class="col-md-6 w-auto mx-auto">
<input type="checkbox" id="type_of_injury9" value="Injury/illness not listed" name="type_of_injury_item[]" data-format="checkbox" class="option-radio ">
<label for="type_of_injury9" class="btn btn-block btn-checkbox hvr-grow type_of_injury9" id="select-option">Injury/illness not listed</label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div id="address-text" style="text-align: center;"></div>
<div class="row step6">
<!-- Back Button -->
<div class="col-6">
<a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
</div>
<!-- NEXT | SUBMIT -->
<div class="col-6">
<button type="button" class="next-link float-right">Next </button>
</div>
</div>
</div>
</div>
<div class="form-footer mt-3">
<p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
</div>
</div>
<div id="step7" class="d-none form-step step-item">
<h2 class="step_heading">Have you incurred any medical expenses because of the related injury or illness caused by the accident? </h2>
<div class="hero-form mt-4">
<div class="row form-fill">
<div class="col-md-6">
<input type="radio" id="medical_expenses1" value="Yes" name="medical_expenses" data-format="radio" class="option-radio ">
<label for="medical_expenses1" class="btn btn-block btn-radio hvr-grow medical_expenses1" id="select-option">Yes</label>
</div>
<div class="col-md-6">
<input type="radio" id="medical_expenses2" value="No" name="medical_expenses" data-format="radio" class="option-radio ">
<label for="medical_expenses2" class="btn btn-block btn-radio hvr-grow medical_expenses2" id="select-option">No</label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div id="address-text" style="text-align: center;"></div>
<div class="row step7">
<!-- Back Button -->
<div class="col-6">
<a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
</div>
<!-- NEXT | SUBMIT -->
<div class="col-6">
</div>
</div>
</div>
</div>
<div class="form-footer mt-3">
<p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
</div>
</div>
<div id="step8" class="d-none form-step step-item">
<h2 class="step_heading">Are you currently working?</h2>
<div class="hero-form mt-4">
<div class="row form-fill">
<div class="col-md-6">
<input type="radio" id="working1" value="Yes" name="working" data-format="radio" class="option-radio ">
<label for="working1" class="btn btn-block btn-radio hvr-grow working1" id="select-option">Yes</label>
</div>
<div class="col-md-6">
<input type="radio" id="working2" value="No" name="working" data-format="radio" class="option-radio ">
<label for="working2" class="btn btn-block btn-radio hvr-grow working2" id="select-option">No</label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div id="address-text" style="text-align: center;"></div>
<div class="row step8">
<!-- Back Button -->
<div class="col-6">
<a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
</div>
<!-- NEXT | SUBMIT -->
<div class="col-6">
</div>
</div>
</div>
</div>
<div class="form-footer mt-3">
<p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
</div>
</div>
<div id="step9" class="d-none form-step step-item">
<h2 class="step_heading">Have you incurred any wage loss because of the injury or illness caused by the accident?</h2>
<div class="hero-form mt-4">
<div class="row form-fill">
<div class="col-md-6">
<input type="radio" id="loss_of_income1" value="Yes" name="loss_of_income" data-format="radio" class="option-radio ">
<label for="loss_of_income1" class="btn btn-block btn-radio hvr-grow loss_of_income1" id="select-option">Yes</label>
</div>
<div class="col-md-6">
<input type="radio" id="loss_of_income2" value="No" name="loss_of_income" data-format="radio" class="option-radio ">
<label for="loss_of_income2" class="btn btn-block btn-radio hvr-grow loss_of_income2" id="select-option">No</label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div id="address-text" style="text-align: center;"></div>
<div class="row step9">
<!-- Back Button -->
<div class="col-6">
<a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
</div>
<!-- NEXT | SUBMIT -->
<div class="col-6">
</div>
</div>
</div>
</div>
<div class="form-footer mt-3">
<p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
</div>
</div>
<div id="step10" class="d-none form-step step-item">
<h2 class="step_heading">Do you believe that another person or organization caused or partly caused the injury or illness?</h2>
<div class="hero-form mt-4">
<div class="row form-fill">
<div class="col-md-6">
<input type="radio" id="someone_caused_injury1" value="Yes" name="someone_caused_injury" data-format="radio" class="option-radio ">
<label for="someone_caused_injury1" class="btn btn-block btn-radio hvr-grow someone_caused_injury1" id="select-option">Yes</label>
</div>
<div class="col-md-6">
<input type="radio" id="someone_caused_injury2" value="No" name="someone_caused_injury" data-format="radio" class="option-radio ">
<label for="someone_caused_injury2" class="btn btn-block btn-radio hvr-grow someone_caused_injury2" id="select-option">No</label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div id="address-text" style="text-align: center;"></div>
<div class="row step10">
<!-- Back Button -->
<div class="col-6">
<a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
</div>
<!-- NEXT | SUBMIT -->
<div class="col-6">
</div>
</div>
</div>
</div>
<div class="form-footer mt-3">
<p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
</div>
</div>
<div id="step11" class="d-none form-step step-item">
<h2 class="step_heading">To successfully pursue a claim, we must be able to identify the party responsible for the accident and injury. If your injury occurred because of your actions, on its own or without any incident or event, it is unlikely
we will be able to assist you with a Public Liability claim. Do you understand? </h2>
<div class="hero-form mt-4">
<div class="row form-fill">
<div class="col-md-6">
<input type="radio" id="understanding1" value="Yes" name="understanding" data-format="radio" class="option-radio ">
<label for="understanding1" class="btn btn-block btn-radio hvr-grow understanding1" id="select-option">Yes</label>
</div>
<div class="col-md-6">
<input type="radio" id="understanding2" value="No" name="understanding" data-format="radio" class="option-radio ">
<label for="understanding2" class="btn btn-block btn-radio hvr-grow understanding2" id="select-option">No</label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div id="address-text" style="text-align: center;"></div>
<div class="row step11">
<!-- Back Button -->
<div class="col-6">
<a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
</div>
<!-- NEXT | SUBMIT -->
<div class="col-6">
</div>
</div>
</div>
</div>
<div class="form-footer mt-3">
<p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
</div>
</div>
<div id="step12" class="d-none form-step step-item">
<h2 class="step_heading">What is your date of birth?</h2>
<div class="hero-form mt-4">
<div class="row form-fill">
<div class="col-md-4">
<div class="input-box py-2">
<select name="dob_day" id="dob_day" class="form-control form-custom custom-select " required="required" aria-required="true">
<option value="" selected="" disabled="" hidden=""></option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<label for=" dob_day">Day</label>
</div>
</div>
<div class="col-md-4">
<div class="input-box py-2">
<select name="dob_month" id="dob_month" class="form-control form-custom custom-select " required="required" aria-required="true">
<option value="" selected="" disabled="" hidden=""></option>
<option value="1">Jan</option>
<option value="2">Feb</option>
<option value="3">Mar</option>
<option value="4">Apr</option>
<option value="5">May</option>
<option value="6">Jun</option>
<option value="7">Jul</option>
<option value="8">Aug</option>
<option value="9">Sep</option>
<option value="10">Oct</option>
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<option value="2005">2005</option>
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<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
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<option value="1974">1974</option>
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<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
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<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
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<option value="1961">1961</option>
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<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
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CLAIM MATE Check Eligibility CLAIM MATE SUFFERED AN INJURY OR ILLNESS CAUSED BY AN ACCIDENT IN A PUBLIC PLACE? YOU MAY BE ENTITLED TO A RANGE OF COMPENSATION BENEFITS. 60 Second Eligibility Check HAVE YOU BEEN INJURED IN A PUBLIC PLACE? Yes No Confidential, Safe and Secure HAVE YOU BEEN INJURED IN A PUBLIC PLACE? Yes No Confidential, Safe and Secure IN WHICH STATE DID THE ACCIDENT OCCUR? Queensland New South Wales Victoria Australian Capital Territory Western Australia Tasmania South Australia Northern Territory Outside of Australia Select your State Back Next Confidential, Safe and Secure HOW LONG AGO DID THE ACCIDENT OCCUR? 1 year or less 1 year or more Back Confidential, Safe and Secure AS A RESULT OF THE ACCIDENT, DID ANY OF THE FOLLOWING OCCUR? CAN SELECT MULTIPLE ANSWERS Loss of life Physical injury Psychological injury Other Back Next Confidential, Safe and Secure WHAT TYPE OF MEDICAL ATTENTION HAVE YOU SOUGHT DUE TO THE INJURY OR ILLNESS CAUSE BY THE ACCIDENT? CAN SELECT MULTIPLE ANSWERS Physiotherapy Surgery General Practice Occupational Therapy Other None Back Next Confidential, Safe and Secure WHAT TYPE OF INJURIES WERE SUSTAINED BECAUSE OF THE ACCIDENT? CAN SELECT MULTIPLE ANSWERS Back or neck injury Hip, knee, or ankle injury Shoulder, elbow, or wrist injury Amputation of a leg, foot or hand Paraplegia or Quadriplegia Injury Psychological illness or injury Head injury Loss of vision or hearing Injury/illness not listed Back Next Confidential, Safe and Secure HAVE YOU INCURRED ANY MEDICAL EXPENSES BECAUSE OF THE RELATED INJURY OR ILLNESS CAUSED BY THE ACCIDENT? Yes No Back Confidential, Safe and Secure ARE YOU CURRENTLY WORKING? Yes No Back Confidential, Safe and Secure HAVE YOU INCURRED ANY WAGE LOSS BECAUSE OF THE INJURY OR ILLNESS CAUSED BY THE ACCIDENT? Yes No Back Confidential, Safe and Secure DO YOU BELIEVE THAT ANOTHER PERSON OR ORGANIZATION CAUSED OR PARTLY CAUSED THE INJURY OR ILLNESS? Yes No Back Confidential, Safe and Secure TO SUCCESSFULLY PURSUE A CLAIM, WE MUST BE ABLE TO IDENTIFY THE PARTY RESPONSIBLE FOR THE ACCIDENT AND INJURY. IF YOUR INJURY OCCURRED BECAUSE OF YOUR ACTIONS, ON ITS OWN OR WITHOUT ANY INCIDENT OR EVENT, IT IS UNLIKELY WE WILL BE ABLE TO ASSIST YOU WITH A PUBLIC LIABILITY CLAIM. DO YOU UNDERSTAND? Yes No Back Confidential, Safe and Secure WHAT IS YOUR DATE OF BIRTH? 12345678910111213141516171819202122232425262728293031 Day JanFebMarAprMayJunJulAugSepOctNovDec Month 2006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925 Year Back Next Confidential, Safe and Secure FINAL STEP! PLEASE FILL OUT INFORMATION BELOW SO YOU CAN RECEIVE YOUR RESULTS First Name Last Name Email Phone Email Back Confidential, Safe and Secure HOW IT WORKS 3 STEPS TO CLAIMING COMPENSATION BENEFITS UNCOMPLICATED AND STRESS-FREE STEP 1 SEE IF YOU QUALIFY Take the quiz from your phone, tablet or desktop to find out if you are eligible for compensation benefits from one of our approved partners. STEP 2 RECEIVE CONSULTATION You will receive a consultation to assess your application with zero obligations to proceed. STEP 3 REVIEW Compare and review your options easily with the help of a legal specialist. Check eligibility FREE ELIGIBLITY CHECK FIND OUT IN UNDER 60 SECONDS IF YOU ARE ELIGIBLE FOR COMPENSATION BENEFITS FROM ONE OF OUR APPROVED PARTNERS To apply you must: Suffered an injury or illness in a public place Injury or Illness occurred within Australia Injury or Illness occurred less then 3 years ago Check eligibility GET STARTED WHAT ARE YOU WAITING FOR? DON'T SUFFER IN SILENCE. SEE IF YOU'RE ENTITLED TO COMPENSATION BENEFITS FOR YOUR INJURY OR ILLNESS Get Started Now Claim Mate is a referral service, we refer all enquiries that are initiated on this website to partners who are licensed to provide their respective products and/or services and quotes. We receive referral fees and commissions from third parties companies for making these introductions. Although we cover a wide range of products and services, we don’t cover every product or service available on the market. In some cases, we may not have a large selection of partners on board who can service your specific request. This could be due to your circumstances that may be unique and only serviceable by a particular provider or because Claim Mate only has been able to come to an agreement with one product or service supplier. By clicking on the “SUBMIT” button, you agree to proceed with a specific product or service offering through a referral from https://apply-public-injury.claim-mate.com, you will be dealing directly with the third party companies and(or) its representatives of that product or service and no longer with https://apply-public-injury.claim-mate.com / Claim Mate. You acknowledge and agree to receive notices, phone calls, and any other communications at the email or telephone number(s) you provided on your application from the third party companies and(or) its representatives of that product or service. The information provided on https://apply-public-injury.claim-mate.com is for general informational purposes only and is not intended to be a substitute for professional legal advice. Claim Mate does not guarantee the accuracy of the information on the website or in any other subsequent communication, including information provided by contributors or third parties at any particular time. We strongly advise that you seek advice from a qualified legal professional before taking any action based on the information provided. Please note that every case is unique, and the information presented may not be applicable to your individual circumstances. You must accept sole responsibility associated with using the material on this website, and the information provided is not a substitute for legal advice. Therefore, you must not rely on the information provided on https://apply-public-injury.claim-mate.com or the Claim Mate website to make any legal decisions regarding your injury or illness. By submitting your details on this site, you are agreeing to the Terms & Conditions and have read and understood the Privacy Policy. © Copyright Claim Mate 2024. All rights reserved. 903/50 Clarence St, Sydney, NSW, 2000 Terms & Conditions | Privacy Policy | Contact Partner with us