m Was the injured employee doing the work he/she should have been
doing and in the correct way?
If no, please give full details
Names and addresses of witnesses. If employees of yours state
o Nature of the injuries (please give as much detail as possible)
p If removed to hospital or otherwise medically examined state name
and address of hospital or doctor
q State date (dd/mm/yyyy) on which employee:
i Left off work
ii Returned to any part of former work
iii If not yet returned, date expected to resume
r Have you received notice of claim? Yes No
If yes, from whom, when and in what form (if claim in writing please
forward with this form)
ircumstances of the Claim
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.
I/We declare these particulars are true and complete in every respect.
Insurers and their agents share information with each other to prevent fraudulent claims and to decide whether to accept your proposal and,
if so, on what terms via the Claims and Underwriting Exchange Register, operated by Insurance Database Services Ltd. A list of participants
is available on request. The information you supply on this form, together with the information you have supplied on your application form
and other information relating to the claim, will be provided to participants.
Signature Date (dd/mm/yyyy)
Designation of Signatory
NIG policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds LS1 4AZ.
Registered in England and Wales No 1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority
and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.
Calls may be recorded.