{"text":"Our Ref:ggi&i W 8 1CC \nACCESS TO PERSONAL INFORMATION \nS Date of Birth: A Q \/ Q\u2018\ufb02_x 3 Q Date of Accident; ! k ! et ___C_);_\u2014_ \n} \" National Insurance Number \u00a7 PYHMG 8L Q) \n\u2019 Address and Postcode { Including former address If changed since accident) \n...... 2 RN O VA \nCSU ;Q\\Q){%}D ...... Po\ufb02code\ufb01\ufb01)f)\u2019qHH \nWere you off work as a result of the accident? \nif YES, please state how long: ......... Months ......... Weeks . j\u2014- Dayy\u2019 \nEmployer's name and address, mm L@b\\\ufb01\u2018.\ufb01 .............................. \nNature of Duties.. \\\u201cC.\\QEI' K\ufb02r ..... et e e \nDid you attend a NHS Hospital as a resuit of the accident? W&\/ NO \n\u2014 \nWere any X-rays taken? 5\/ NO \nPlease give full name and address of the Hospital: \n...................................................................................................................... \n. ' Please tell us about any injury sustalned in as much details as possible: \nW8 SR :\ufb01rEC!E.\\VQdL (Ytad\\cgbor\\ \\ Asa. P\\:@% ga\u00e9\ufb02 iy \nOwn General Practltloner s hame & address: \n...................................................... \n| CONSENT FOR GENERAL PRACTITIONER'S | HOSPITAL \/ EMPLOYMENT RECORDS _| \n| hereby consent to the disclosure of my Employment and \/or Hospital Records and \/ or \nGeneral Practitioner\u2019s records (past & present) to DIRECT LINE GROUP SERVICES or \nto their appointed representative for the purpose of supporting my claim for \ncompensation. \n,s|gned....\u00a3..}.\u2018\/am\u00ab\u00e9 ............................ Dated: '=t \\\u2019\/ ;5\u2018{ | Oy . \nt\u00bbs\\ \n. ) \u2018 400N \nPLEASE COMPLETE AS FULLY AS POSSIBLE TO AID THE SWif\u2018rc\u2018,PROG\u2019ESgIt}G OF YOUR CLAIM \nBest Practice \nGLASGOW \n\\! \\\\ 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