Name of the Insured
Town County
Postcode Date Premium Paid
Occupation Telephone Number
Policy Number Value Added Tax. Are you
a registered person or company? Yes No
Name of Employee
Town County
National Insurance No. Occupation
Date of Birth
Age Marital Status
You the Policyholder
General Information
a Was he/she in your employ and pay? Yes No
b If he/she is in your direct employ were instructions/supervision given
by your employees?
Yes No
c If he/she is employed by or receives instructions/supervision from a
contractor to you or persons/company to whom you are contracted,
state their name/address
d The following documents are requested:
You should not delay the submission of this form if any of the above are not readily available
Pre-action Protocol and Fast Track Discovery Tick () appropriate box
Enclosed Available Not held
1 Accident book entry
2 First Aider’s report
3 Foreman/Supervisor’s accident report
4 Safety representatives accident report
5 Riddor report to HSE
6 Other communications between defendants/HSE
7 Minutes of Health & Safety committee/meetings where accident/matter considered
8 Report to DSS
9 Documents relative to any previous accident/matter identified by the Claimant and relied upon as proof of negligence.
Employers’ Liability Claim Form
NIG Commercial Claims P O Box 1151 Bromley BR1 9WB
Please note - you can complete this form on screen. When completing please use the tab and arrow keys to move between the relevant
fields. Ensure you do not use the return or enter keys.
If completing by hand, please answer all questions using BLOCK CAPITALS.
e Date of commencement of employment?
f For the 52 weeks prior to the accident, please state:
i G
ross earnings
ncome Tax deducted
iii N.H.I. benefits deducted iv Net Earnings
Please indicate total number of weeks (if not 52 weeks)
g State total periods of absence in 52 weeks prior to accident divided
into causes:
Period Paid/Unpaid?
Period Paid/Unpaid?
h If employment was of casual nature, state:
i How was he/she being paid
hat was the weekly average
iii Details of any deductions
iv Payments from any other employers
eneral Information
a Date of Accident (dd/mm/yyyy) Time
am pm
b Place
c When was the accident first reported to you or your representative?
d Describe nature of work being performed at the time of the accident
e Description of the accident
f If the accident involves machinery:
i was it properly guarded? Yes No
ii was the guard in use Yes No
g Has H.M Factory Inspector examined the machinery/premises since
the accident?
Yes No
If yes, date of examination (dd/mm/yyyy)
Was the accident caused by negligence? Yes No
i Name and address of negligent person
j Name and address of negligent employers
k Details of the negligence
l Name and position of person in authority over injured employee
Circumstances of the Claim
m Was the injured employee doing the work he/she should have been
doing and in the correct way?
es No
If no, please give full details
Names and addresses of witnesses. If employees of yours state
heir position(s)
i Name
ii Name
iii Name
iv Name
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.