Title: NHS charges, contributory negligence - request liability review (CRU 1503 form(

Contributory Negligence Template – in respect of review requests relating to contributory negligence claims under The Health and Social Care (Community Health and Standards) Act 2003 supported by Section 3 of The Personal Injuries (NHS Charges) (General) and Road Traffic (NHS Charges) (Amendment) Regulations 2006.

1. Name of injured person (claimant)______________________________

2. CRU reference____________

3. Date of incident____________

4.    (a) Amount of damages agreed had there been no contributory negligence £__________

       Amount of damages paid due to finding of contributory negligence £________

       Or

       (b) The agreed percentage of contributory negligence _____% (rounded to nearest full percent)

Name of Compensator_____________________      

Signature____________________

Date_______________

Name of claimant (or rep)____________________

Signature_________________________

Date_______________

(Electronic signatures are not acceptable)

of                                                             CRU1503
Please note that it is not compulsory to use this form in contributory negligence cases. It is provided to assist compensators where the negotiation process has not included sufficient evidence e.g. negotiated via telephone or email. The CRU will accept a variety of evidence that constitutes a signed report, as long as it clearly demonstrates acceptance of contributory negligence by the claimant and the proportion of damages, of the full value of the case, that were paid.