Name/Insured *		Policy Number
Address		Postcode
		Daytime Phone * (Inc. area code)
Business		Contact
Fax No.		Email Address *

Date	12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 2008200720062005200420032002200120001999199819971996	Time	123456789101112 : 00153045 am   pm
Location		When was it first notified to you
By whom?		Has a record of the accident been made? (if yes attach copy)	Yes     No

State fully what happened	Has any similar occurrence previously taken place?	Yes     No
	Details:

What precautions against the accident/injury had previously been taken?		What plant or equipment, if any, was involved? (any relevant equipment must be kept for inspection)

Was it properly guarded?	Yes     No	Was guard in use?	Yes     No
Has any Authority investigated since the event?	Yes     No	Details

Name & Addresses of all witnesses (if written statements obtained, please attach)

Name of person in charge at the time

If an Accident was caused by a person not in your employ, state their and their employers’ name and address	Name & Place of any hospital to which injured person taken

Name		Date of Birth	12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 2008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900
Address		Postcode
		Occupation
National Ins. No.		State length of experience In this type of work
Is he/she in your direct employ?	Yes     No	If so, how long?

State any physical defect or relevant medical history prior to the event

Date ceased work following accident

12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 2008200720062005200420032002200120001999199819971996

Date returned to work following recovery

12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 2008200720062005200420032002200120001999199819971996

Employee's Wage Details (if applicable) Please give details of injured employees earnings for thirteen weeks prior to the accident.

Week Ending (dd/mm/yyyy) Gross Pay Income Tax NI Contributions Supplements Net Pay after tax & NI £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £

Statutory sick pay

£

Other Payments

£

You may upload an attachment related to this claim:
Click the 'Browse' button to locate the file on your PC you wish to attach to your claim

I declare that the above statements are true and correct to the best of my knowledge and belief

I have not withheld any information within my knowledge connected with this form

I agree to provide the Insurer with any further information or documentation as may be reasonably required

I understand that the Insurer does not admit liability by the issue of this form

I confirm I am authorised to provide information contained in this form

I confirm that I have read and understand the above declaration. *  

Full Name: *		On behalf of: (if applicable)
Date:	11/10/2008	Position:
Note: After you click 'Submit' there will be a short pause while we process your form. Please wait until you receive a confirmation message.