Claimant First name ^*

Claimant Last name ^*

Claimant Organisation (if applicable)

Claimant Email Address ^*

Claimant Phone number

Contact PreferenceEmailPhone

Is an agent acting on behalf of the claimant ^*NoYes

Name of Publisher ^*

Name of Publication

Is the claim currently subject to legal proceedings? ^*YesNo
Please note that Impress will not refer to arbitration matters where the cause of a claim is already subject to litigation

Have you previously brought the claim to the attention of the publisher? ^*YesNo

Does the claim seek to prevent publication? ^*YesNo

In accordance with which law does the claimant request the dispute to be settled? ^*England & WalesScotlandNorthern Ireland

Please provide a summary of the article or act by an Impress regulated publication which has prompted this claim. ^*
If the claim relates to a publication, please specify any relevant words, phrases or any other aspects of the article(s) that have breached your civil rights.

When was the article first published / did the first event occur, and over what period of time did it persist? ^*

If the claim is in relation to a publication, please provide the following details:

Article Headline

Social Media Post

URL link to Article or Social Media Post

Attach File/Screenshot

If possible, please make a list of the key facts you believe you will need to prove and the main types of evidence you believe will be available to prove each of them.
Types of evidence can include oral or written statements given by you or others

If there are particularly complex factual disputes and/or unusual issues of law that you believe need to be resolved in order to fairly decide your claim, please give details.

Please provide any further details, or any additional documentation/evidence, in relation to your request.

Attach File

In what ways is it believed that the harm or loss suffered has been caused by the publication?^*

What is the nature and extent of the harm or financial loss believed to have been suffered?^*

How much do you intend to claim from the publisher to compensate you for the harms and losses you have identified (if anything) and how have you calculated this figure?^*

Besides any claim for compensation, what is the requested remedy or sanction you seek?^*
E.g. award and/or direction of: damages; publisher displaying summary of the award; publisher not re-publishing the information or statement in respect of which the claim has been brought.

Please state if there is any particular form of assistance you require to fully participate in the process. Impress will then consider what it can do to help.