Beer advocaten: Aanmeldingsformulier

If you wish to present your case to Beer advocaten, please fill in the application form. This information will then be discussed with one of our partners, who will assess whether your case falls within the firm’s areas of expertise, and if so, whether one of our lawyers can take on your case.

The questions below will help you to describe the matter. Once you have completed and submitted the form, you will receive an e-mail acknowledging receipt, with a copy of the completed form for your records. We use secure connections to keep your details confidential.

Initials*

Last name*

Street address

Postcode

City*

Gender*

Male
Female
-

Date of birth*

Telephone*

What is your profession/occupation?

Married/cohabiting/single?

Are you the breadwinner?

Incident causing injuries*

Traffic accident
Medical error
Workplace accident
other:

Circumstances of incident causing injuries*

Date of incident causing injuries*

The answer is important because of the limitation periods. If you do not know the exact date, please fill out "00-00-0000”, for instance in case of ongoing medical errors.

Has the responsible party been held liable?

No
Yes

Has liability been admitted?

No
Yes
Don't know

If so, please state the name of the liable party and that party’s insurer.

Please list your current loss items and estimate the amount concerned.*

Are you (temporarily) unfit for work because of the incident?*

No
Yes

Work situation at the time of the incident*

In salaried employment
Self-employed
Benefit recipient
N.a.

If in salaried employment

Permanent contract
Temporary contract
N.a.

How did you hear about us?

Have you been in contact with our office before?

No
Yes

I agree that these data will be retained and may be used to appraise my case, until the intake department has taken my application form under consideration. *

Click here to read our privacy statement

To make sure that you are not a robot, we ask you to click the box on the right. You will possibly see a couple of pictures, with instructions. If you follow the instructions, you can submit the form. If you skip this step, this will not work and your data may be lost.

Security image. You must enable images to submit entry

Enter what you see:

(Case sensitive)