Policy Holder Details

Name of the Insured:

Address:

Town:

County:

Postcode:

Email:

Telephone:

Policy Reference:

Policy Start Date:

Employee Details

Employee Name:

Employee Occupation:

Address:

Town:

County:

Postcode:

National insurance No:

Date of Birth:

Employee Age:

Marital Status:


General Information

Was he/she in your employ and pay:

If he/she is in your direct employ were instructions/supervision given by your employees:

If he/she is employed by or receives instructions/supervision from a contractor to you or a persons/company to whom you are contracted, state their name/address:

General Information (Continued)

Date of commencement of employment:

Earnings

For the 52 weeks prior to the incident please state the following:

Gross Earnings:

Income Tax Deducted:

N.H.I. benefits deducted:

Net Earnings:

Please indicate the number of weeks (If not 52 weeks):

Absences

State the total periods of absences in 52 weeks prior to accident divided in causes:

Cause

Period

Paid/ Unpaid

How was he/she being paid:

What was the Weekly average:

Details of Deductions:

Payments from any other employers:



Circumstances of the Claim

Date of Incident:

Location:

When was the accident first reported to you or your representative:

Describe the nature of the work being performed at the time of the accident:

Description of the accident:

If the accident involves machinery:

Was it properly guarded:

Was the guard in use:

Has H.M. Factory Inspector examined the machinery/premises since the accident:

If yes, date of examination

Negligence

Was the accident caused by negligence:

Name and address of negligent person:

Name and address of Negligent employers:

Details of Negligence:

Name and position of person in authority over injured employee

Name:

Position:



Circumstance of the claim (continued)

Was the injured employee doing the work he/she should have been doing and in the correct way:

YesNo

If no, please give full details:

Names and addresses of witnesses. if employees of yours state their positions:

Name

Position

Name of the injuries (please give as much detail as possible):

If removed to hospital or otherwise medically examined state name and address of hospital or doctor:

Date Employee left work:

Returned to any part of former work:

If not yet returned, date expected to resume:

Have you received notice of claim:

YesNo

If Yes, from whom, when and in what form (if claim in writing then please forward onto us or attach to this form):


Signature:

Date: