The Business Insurance Bureau


    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:




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