Policy Holder DetailsName of the Insured:Address:Town:County:Postcode:Email:Telephone:Policy Reference:Policy Start Date:Employee DetailsEmployee Name:Employee Occupation:Address:Town:County:Postcode:National insurance No:Date of Birth:Employee Age:Marital Status:NextGeneral InformationWas he/she in your employ and pay:Please selectYesNoIf he/she is in your direct employ were instructions/supervision given by your employees:Please selectYesNoIf 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:EarningsFor 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):AbsencesState the total periods of absences in 52 weeks prior to accident divided in causes:CausePeriodPaid/ UnpaidHow was he/she being paid:What was the Weekly average:Details of Deductions:Payments from any other employers:Back NextCircumstances of the ClaimDate 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:Please SelectYesNoWas the guard in use:Please SelectYesNoHas H.M. Factory Inspector examined the machinery/premises since the accident:If yes, date of examinationNegligenceWas the accident caused by negligence:Please SelectYesNoName and address of negligent person:Name and address of Negligent employers:Details of Negligence:Name and position of person in authority over injured employeeName:Position:Back NextCircumstance of the claim (continued)Was the injured employee doing the work he/she should have been doing and in the correct way:YesNoIf no, please give full details:Names and addresses of witnesses. if employees of yours state their positions:NamePositionName 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:YesNoIf Yes, from whom, when and in what form (if claim in writing then please forward onto us or attach to this form):Signature:Date:Back