Dedicated Barbican Liability Claims Notification Form





Employer/Insured
Employer/Insured Name
Employer/Insured Address

Street Address

Address Line 2

City

Country
Type of Business
Contact Telephone Number


Employee/Injured Party
Employee/Injured Party Name
Employee/Injured Party Address

Street Address

Address Line 2

City

Country
Occupation
Date of birth

MM 		/
DD 		/
YYYY
Date Employee Commenced Employment

MM 		/
DD 		/
YYYY
NI Number


Accident
Date/Time of Accident

MM 		/
DD 		/
YYYY
HH 		:
MM
AM/PM
Location
Date/Time Reported

MM 		/
DD 		/
YYYY
HH 		:
MM
AM/PM
Details & Address of Witnesses
Name of Hospital taken to
Insured's comments on allegations/circumstances of incident
Please provide wage details for 13 weeks prior to the accident using the boxes below, in the format of Gross Wage/Net Wage.

 e.g. If for Week 1 Gross Wage was 1000 and Net Wage was 600, in the box beside Week 1 input: 1000/600.
Week 1    
Week 1 Ending Date    
Week 2    
Week 2 Ending Date    
Week 3    
Week 3 Ending Date    
Week 4    
Week 4 Ending Date    
Week 5    
Week 5 Ending Date    
Week 6    
Week 6 Ending Date    
Week 7    
Week 7 Ending Date    
Week 8    
Week 8 Ending Date    
Week 9    
Week 9 Ending Date    
Week 10    
Week 10 Ending Date    
Week 11    
Week 11 Ending Date    
Week 12    
Week 12 Ending Date    
Week 13    
Week 13 Ending Date    
Additional information and comments as to the circumstances of the accident and who the Insured believe to be at fault


 

  
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fax: 0870 839 0939
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