ࡱ> #` bjbj Tv"JJJ$n&&&P&'nN)$0$0$01ʼn Q,}$ȱh08#J;ʼn#$01V8$0J1:,2J:0lB) c&/| AƯ0 hhhJ@ߛot##nnn$ &nnn&nnn  eClaim form Employer s liability InsuredPlease complete the form as fully as possibleZurich Claim Number FORMTEXT      Name FORMTEXT HERIOT-WATT UNIVERSITYPolicy Number FORMTEXT NHE  FORMTEXT 15CA010013  FORMTEXT    Incident / claim detailsFull incident circumstances and details of injury suffered FORMTEXT      What instructions / training was given to the employee about the specific task involved? FORMTEXT      Were these instructions followed? FORMDROPDOWN Date of incident  FORMTEXT      Time of incident FORMTEXT      For gradually occurring injuries, such as disease, stress, etc. please state period of the alleged exposureFrom  FORMTEXT       to  FORMTEXT      Has a formal claim been made? FORMDROPDOWN  Location of incidentAddress  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Postcode FORMTEXT      Is the land / property within your ownership? FORMDROPDOWN If not, please state your involvement / resposibilities? FORMTEXT       Claimant details  the injured personWas the injured person in your direct employment? FORMDROPDOWN Department FORMTEXT      FORMTEXT      Title FORMTEXT      Initial FORMTEXT     Surname FORMTEXT      Address FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Postcode FORMTEXT      Phone number FORMTEXT      N.I. number FORMTEXT      Date of birth FORMTEXT      Occupation FORMTEXT      FORMTEXT      Date employment commenced with you FORMTEXT      Employment status FORMTEXT      FORMTEXT      If fatal, give details of know dependants FORMTEXT      Name of line manager / supervisor FORMTEXT      Phone number FORMTEXT       Claimant representative (if applicable)Name FORMTEXT      Reference FORMTEXT      Address FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Postcode FORMTEXT      Phone number FORMTEXT      Claim Number FORMTEXT       Claim Number FORMTEXT      Documentation - Please forward all relevant documentation.All communications with the Health & Safety Executive FORMDROPDOWN DSS form B176 FORMDROPDOWN Your safety officers report FORMDROPDOWN Accident book entry FORMDROPDOWN HSE form F2508 / RIDDOR FORMDROPDOWN First aid book entry FORMDROPDOWN Health & Safety committee meeting minutes where accident / complaints discussed FORMDROPDOWN Employees training records FORMDROPDOWN Pre-accident risk assessments FORMDROPDOWN Post-accident risk assessments FORMDROPDOWN Net wage information for 13 weeks prior to absence / accident FORMDROPDOWN Net wage information for period of absence due to accident FORMDROPDOWN Letter of claim from claimant / representative FORMDROPDOWN Line manager / supervisors report FORMDROPDOWN  Witness evidence details of anyone who witnessed the incidentTitle FORMTEXT  "$&PRTd      2 4 6 ~kX~~E%jh,)he5;CJU$jh,)5;CJUmHnHu%jh,)he5;CJUh,)he5;CJjh,)he5;CJUh,)he5CJh,)heCJh,)h,)CJh,)heOJQJjh,)heOJQJU(jh,)heOJQJUmHnHuh&8heOJQJheCJOJQJmHnHu "PTd $If $$Ifa$ $$Ifa$ & F$If dhgd,)@& ̕   f gaaaa$Ifkd$$Ifl4d\ !* 04 lalf46 b d f 0 2 ׻רוtdtUjh,)he5CJUh,)he5CJmHnHuh,)heCJmHnHu$jh,)5;CJUmHnHu%j!h,)he5;CJU%jh,)he5;CJU%j)h,)he5;CJUh,)heCJh,)he5;CJjh,)he5;CJUh55CJmHnHu 0 ge[ & F$Ifkd$$Ifl4e\}*04 lalf40 2 +qkd$$Ifl40*04 lalf4$If[kdl$$IflP**04 lal     < > R T V ` b d ԺԺr"j h,)he5CJU"j h,)he5CJU"jh,)h,)5CJU"jNh,)he5CJUh,)heCJ!jh,)5CJUmHnHujh,)he5CJU"jh,)he5CJUh,)he5CJ%  qkd$$Ifl40*04 lalf4$If  < d $Ifqkdk$$Ifl40*04 lalf4 gaa$Ifkd4 $$Ifl4\* 04 lalf4 &(DFHNxĻĩěĉߛygU"jXh,)he5CJU"jh,)he5CJUh,)he5CJmHnHu"j h,)h,)5CJUh,)heCJmHnHu"j h,)he5CJUh,)heCJh,)he5CJ!jh,)5CJUmHnHujh,)he5CJU"j h,)he5CJU! 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FORMDROPDOWN Is there any likelihood of medical retirement as a result of the accident? FORMDROPDOWN  Additional information and declarationAdditional information FORMTEXT      By submitting this completed form I declare that all answers are true and correctDate FORMTEXT      Contact name FORMTEXT Lorraine LoyJob Title FORMTEXT Group Risk ManagerAddress FORMTEXT Heriot-Watt University, Group Risk Office, Riccarton, Currie, EdinburghPostcode FORMTEXT EH14 4ASE-mail address FORMTEXT l.loy@hw.ac.ukPhone number FORMTEXT 0131 451 8087Your reference FORMTEXT      Are you VAT registered? FORMDROPDOWN What percentage recovery can you make from customs and excise? FORMTEXT       %Claim Number FORMTEXT           Zurich Municipal is a trading name of Zurich Insurance company. A limited company incorporated in Switzerland. Registered in the canton of Zurich. No. CH-020.3.929.583-0 UK branch registered in England. No. BR105. 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