Accident at Work Claim Form

Personal Details

Name*
Address*
Postcode*
Tel. no.*
Email*
Date and Time of Accident*
Please indicate items you wish to claim for	Damage to clothes / goods and other items of loss Loss of income Personal injury

Claim for Personal Injury / Loss of Income

Employer Name*
Job Type
Employer Address*
Work Roll No.
National Ins. No.
Date of Birth*

Other Information

Please give brief details of how the accident occurred
Which department do you work in?
Were you working on a machine at the time of the accident?	Yes No

Names and addresses of any witnesses

Who did you report the accident to?
Was the accident entered in the accident book?	Yes No
Was the Health and Safety Executive informed of the accident?	Yes No
Are you a member of a Union?	Yes No

Losses

As a result of the accident you may have suffered other losses such as travelling expenses, e.g. taxis or bus fares to hospital or work. Below are a set of standard questions of which some may be relevant to your circumstances. If you have suffered any loss of a type not listed please give details in the space provided at the end of the standard questions.

Please give details of travel expenses suffered as a direct result of the accident and forward copy receipts if available.

Please give details of items of clothing or other items damaged as a result of the accident and forward copy of receipts for the items or their replacement if possible.

If you have suffered any other losses please advise below.

Loss if income

Have you suffered any losses of income as a result of accident, if so please give details
Number of days absent from work (state if continuing)
Job Description
Gross Salary	Weekly Monthly
Net Salary	Weekly Monthly

(Please provide evidence of your income in the form of wage slips to cover a period of 13 weeks prior to the accident (or letter from employer)

Please do not delay submitting this form if you are unable to provide wage slips at this stage.

Do you have any objections to us writing to your employers to obtain details / confirmation of your loss?	Yes No

	I agree that the above information is true and correct to the best of my knowledge and belief at this time.

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