Potential Claimant's Online Submission Form

Please supply us with as much information as possible to enable us to assess the merits of your claim. If you do not know the answer to a particular question or do not wish to provide information (for example if it is sensitive) we can deal with any outstanding issues by telephone or email.

1. Please supply details of your relationship to the person who has died?

   Help : Section 1 (1) of the 1975 Act sets out the classes of person who may make a claim under the act. These are listed below, please select as appropriate and provide details.
   The husband or wife or civil partner of the deceased.

   A former husband or wife or civil partner of the deceased.

   A child of the deceased.

   A person who lived in the same household as the deceased.

   Note : You must have lived for the 2 years immediately prior to the deceased’s death as husband and wife or as civil partners.

   Any person (not a child of the deceased) who was treated by the deceased as a child of the family.

   Note : Your parent must have been married or entered a civil partnership with the deceased and from that relationship you were treated as a child of the family.

   Any person (not being a person included in any of the above categories) who immediately before death was being maintained, either wholly or partly by the deceased.

   Note : Maintained means that you received support from the deceased either financially or in financial terms (for example by providing accommodation, care or assisting with bills).
2. Please provide specific details of your relationship with the deceased and the support provided.
3. Did the deceased die whilst they were living or domiciled in England and Wales?
   Select Option Yes No Not known

   Help : A person who died domiciled in the England and Wales would have considered England and Wales as their primary residence. If you are unsure please state this and we can make further enquiries.
4. If known, what, if anything, do you receive under the Will/Intestacy?
5. What was the approximate value of the deceased’s assets at the date of death?
   Select Option Less than £100K £100K - £250K £250K - £500K £500K or more Don’t know

   Help : Please provide an indication of the size of the deceased’s estate, this can be found on the Grant of Probate if available. If you are unsure but know of various assets please supply this information in box 12.
6. What is your net annual income?
   Select Option Less than £20,000 £20,000 – £35,000 £35,000 - £50,000 £50,000 - £75,000 £75,000 - £100,000 More than £100,000

   Note : Your own financial circumstances are taken into consideration when bringing a claim under the 1975 Act.
7. Do you have any savings or own any assets, for example a property?
   No.

   Yes - if yes please supply details.
8. Do you have any debts or other liabilities?
9. What are your current financial needs and any likely future financial needs?
10. What was the date of death?
11. Has a Grant of Probate been issued? If yes, what is the date of issue?
    Select Option Yes No Not known Date :
12. Please provide any other details that you think may be relevant.
13. Please provide your name, address, telephone number, email address and date of birth. Please indicate your preferred mode of communication.

Please type the number you see below to verify.