Employers Liability Claim Form 1 Step 1 Section One - Policyholder Name of insured VAT RegisteredYesNo If Yes - VAT Reg Number If Yes - state whether you can recover the VAT relating to the property for which you are claiming Emailemail Private Tel Business Tel Mobile Telno-icon Policy No. Business Name Date Premium Paiddate_range Have you had any previous claims with us or another company?Select An OptionYesNo If so, please provide details on the type of claim, insurer and final settlement amount0 / Section Two - Employee Details Name of Employee Date of Birthdate_range National Insurance No. Occupation Marital Status Address of Employee0 / Section Three - General Information Were they in your employ and pay?Select An OptionYesNo If they are in your direct employ were your interactions/supervision given by your employeesSelect An OptionYesNo If they are employed by or recieves interaction/supervision from a contractor to your or persons to whom you are contracted, state their name/address0 / PROPERTY CLAIM FORMThe following documents are requested. You should not delay the submission of this form if any of the above are not readily available. Accident Book EntryAttached BelowAvailableNot Held First Aider's ReportAttached BelowAvailableNot Held Foreman / Supervisor's Accident ReportAttached BelowAvailableNot Held Safety Representatives Accident ReportAttached BelowAvailableNot Held RIDDOR Report to HSEAttached BelowAvailableNot Held Other communications between defendants / HSEAttached BelowAvailableNot Held Minutes of Health & Safety Committee / meetings where accident / matter consideredAttached BelowAvailableNot Held Report to DSSAttached BelowAvailableNot Held Documents relative to any previous / accident / matter identified by the Claimant and relied upon as proof of negligenceAttached BelowAvailableNot Held Filescloud_uploadUpload Date of commencement of employmentdate_range Gross earningsfor the 13 weeks prior to the accident Income Tax deductedfor the 13 weeks prior to the accident NI benefits deductedfor the 13 weeks prior to the accident Net earningsfor the 13 weeks prior to the accident Please indicate total number of weeks (if not 13 weeks) State total periods of absence in 52 weeks prior to accident divided into causesCausePeriodPaid / Unpaid××+ Add Row(2) How were they being paidif employment was of casual nature What was the weekly wageif employment was of casual nature Details of any deductionsif employment was of casual nature Payments from any other employersif employment was of casual nature Section Four - Circumstances of the claim Date of Accidentdate_range Time000102030405060708091011120030access_time Place0 / When was the accident first reported to you or your representative Describe the work being performed at the time of the accident By whom? Description of the accident0 / Does the accident involve machinerySelect An OptionYesNo Was the machinery properly guardedSelect An OptionYesNo Was the machine guard in useSelect An OptionYesNo Has H.M. Factory Inspector examined the machinery / premises since the accidentSelect An OptionYesNo Date of examinationdate_range Name and address of negligent person0 / Name and address of negligent employers0 / Details of the negligence0 / Name of person in authority over injured employee Position of person in authority over injured employee Was the injured employee doing the work they should have been doing and in the correct waySelect An OptionYesNo If no, give details0 / WitnessesIf employees of yours, please state their position(s)NamePositionAddress××+ Add Row(2) Nature of the injuries. Please give as much detail as possible0 / If removed to hospital or otherwise medically examined, state the name and address of the hospital or doctor.0 / If removed to hospital, was this by an NHS ambulanceSelect An OptionYesNoN/A Was the injured person detainedSelect An OptionYesNo If the injured person was detained, for how many nights Date the injured employee was first unable to work due to this incidentdate_range Date the injured employee returned to any part of former workdate_range Date the injured employee returned to any form of workdate_range Date the injured employee is expected to be able to resume work if not yet returneddate_range Have you received notice of claimSelect An OptionYesNo If yes, from whom, when and in what form (if claim in writing, please attach below)0 / Filecloud_uploadUpload PLEASE DO NOT ENTER INTO ANY CORRESPONDENCE WITH THE INJURED EMPLOYEE OR HIS REPRESENTATIVES. SIMILARLY NO PAYMENTS, OFFERS OR ADMISSIONS OF LIABILITY ARE PERMITTED BY YOUR POLICY. ANY SUCH ACTION COULD PREJUDICE THE POSITION ADVERSELY. IN RESPECT OF FATAL ACCIDENTS OR SERIOUS INJURIES WHICH MAY OR MAY NOT PROVE FATAL IMMEDIATE TELEPHONE NOTIFICATION IS REQUIRED. Section Five - Notice Red Seal Property Ltd will act on behalf of insurers in handling your claim and in the absence of your advices to the contrary, will assume your informed consent to your claim being handled on this basis. Please note that insurers pass information to the claims and underwriting Exchange register, run by Insurance Database Services Ltd (IDS Ltd) The aim is to help us to check information provided and also to prevent fraudulent claims. When you tell us about an incident (such as fire, water damage or theft) which may or may not give rise to a claim, we will pass information relating to it to the register. In accessing claims made insurers may also undertake checks against publicly available information as necessary such as electoral roll, county court judgements, bankruptcy orders or repossessions. Some of the information which you give us about this claim may be passed to other insurance companies you tell us about. They will give us information about your policy with them, and we may ask them to pay a contribution to this claim. A contribution payment is normal practice where two or more policies cover the same thing. If another company contributes to your claim with us, it should not affect any no claims discounts you may have with them. Section Seven - Declaration Please read carefully before signing I hereby confirm that the above information is a true and accurate statement. Unless Red Seal Property Ltd hear from you to the contrary within the next 24 hours the above contained information will be deemed to be a true and accurate record of events. I declare that the above statements are true and correct to the best of my knowledge and belief. I hold no other policy in addition to this one indemnifying me in respect of this claim. I have not withheld from the Insurers any information with my knowledge connected with the loss and I agree to provide the Insurers with any further information or documentation as may be required. I hereby confirm that Red Seal Property Ltd have my authority to recover any outlays on my behalf for monies paid under this contract of insurance in relation to this event. I understand that any attempt to make a fraudulent claim may result in prosecution. Signature(s)of Policyholder(s) Dateagreeddate_range AgreementBy checking this box you agree to let us collect the above information entered by you in this form. We will use this data to handle your claim and contact you regarding it.By checking this box you have read and agree to our Privacy Policy Submit Form If you are having trouble submitting the form then please reload your page and try again. keyboard_arrow_leftPrevious Nextkeyboard_arrow_right
