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Please complete this claim form for all claims.

A claim can be made under EIS if your employee has been absent from work for at least three consecutive working days as a result of a musculoskeletal injury or a mental ill health issue, such as stress, anxiety, or depression.

A claim can also be made where your employee has been involved in a reported motor accident but has not necessarily been absent from work for three consecutive working days.

Make a claim

Contact Details
Company Name*
Your Name*
First Last
This is the name of the person completing the form - NOT the name of the absent employee
Your job title*
Postcode*
Company Address*

Street Address Address Line 2 City County Post Code Country
Your phone number*
Email*
Claimant Details
Claimant Name*
First Last
This is the name of the person who is off work
Claimant D.O.B.*
Day
Month
Year
Claimant job title*
Postcode*
Claimant Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Claimant Email*
Claimant Tel*
We'll prioritise landline calls
Claimant Mobile*
Claim Details
Please select*
Is the absence a result of an incident which occurred whilst at work?*
- Yes
- No
- Unsure
First day of absence*
DD slash MM slash YYYY
Where was the motor accident reported?*
- Police Station
- Insurance Company
Name of the police station or insurance company*
What was the accident reference or claims reference number?*
What was the date of the motor accident?*
DD slash MM slash YYYY
The claimant is suffering from:*
Where is the injury
Declaration
Please confirm*
- Confirmed
I confirm that to the best of my knowledge that all of the information I have supplied is true and complete and I confirm that the claimant has given their informed consent for their personal details to be passed to and processed as required under the policy terms and conditions by Alan Boswell Insurance brokers Ltd and their agents.
Name
This field is for validation purposes and should be left unchanged.

Make a claim

Contact Details

Claimant Details

Claim Details

Declaration