Customer Complaints Form

Section 1: Claimant:
Full Name of the Claimant:
(If the complaint involved more than one person please give us name and contact details)
Country:
Tel:
Email:
Additional Claiment Details:
(If the complaint involved more than one person please give us name and contact details):
Section 2: Faulty Product:
Please identify product(s) involved to include the model and barcode no:
Date of Purchase:
Name and address of store or shop online where the product has been purchased:
Please provide us with evidence of purchase:
Was the product supplied with any special instructions for use?
Was the product supplied with all components?
Has the product been returned by the Claimant to the store or Ashleigh and Burwood for testing?
(If no, please provide us with picture of the product; we may ask you to send the faulty product to Ashleigh and Burwood for technical report):
Section 3: Injured Person:
Please fulfil this section if a person has been injured physically or mentally
Full Name:
Address:
Approximate Age:
Section 4: Incident:
Address where incident occurred:
Date and time of incident:
Give full description of the incident and state exactly how it occurred:
Name, addresses and contact telephone numbers of any witnesses to the incident:
Details of Injury:
What was the injury?
(e.g. fracture, laceration, bruising, etc)
What part of the body was injured?
(e.g. head, leg, finger, etc)
First Aid treatment provided?
Name of First Aider:
What lost time was incurred by the incident:
Section 5 – Material Damage:
Details of Material:
(e.g. furniture, carpet…)
What was the damage?
(e.g. burned, melted….)
Did the material need replacement?
(if yes, please provide with evidence of damage):
When and where the material has been purchased?
(please provide with evidence of purchase or supplier information):
Section 6 - Reporting:
(Major injuries, e.g. fractures, unconsciousness, dislocation; Hospitalised for more than 24 hours; over 3 days absence, including rest days, not including the day of the accident; Dangerous Occurrence, e.g. truck overturning)
IS THE ACCIDENT/INCIDENT REPORTABLE?
HAS THE ACCIDENT/INCIDENT BEEN REPORTED:
DATE OF REPORT:
REPORT REFERENCE NUMBER:
Section 7:
Has the accident/incident been reported to the Police?
Name of Police Officer:
At what Station:
Do you accept responsibility for the accident/incident?
If not, who do you consider responsible and why?
What is the subject of your claim?
Replacement of the product:
Refund of the product:
(please note than refund can occurred ONLY if product was bought on Ashleigh and Burwood web site. If not, please contact your supplier)
Compensation:
Value of compensation in £:
Section 8 - Documents Attached:
(Please attach as many of the following documents as possible)
STATEMENT FROM INJURED PARTY:
SKETCH/MEASUREMENTS:
WITNESS STATEMENT(S):
PHOTOGRAPHS:
SERVICE RECORDS:
OTHER:
If Other, please specify:
Back to Top.