POLICY REFERENCE NUMBER. POLICY NAME Claims Handling Policy. Chief Nurse and Deputy Chief Executive

Transcription

1 POLICY REFERENCE NUMBER SABP/RISK/0034 POLICY NAME Claims Handling Policy BRIEF OUTLINE OF THIS POLICY This policy will provide a framework for the management of claims for compensation made against the Trust. Version Number 6.0 Approving Committee Policy Category Executive Lead Name of Author Executive Board Risk, Health and Safety Chief Nurse and Deputy Chief Executive Legal Services Manager Date Approved 7 th June 2018 Date Issued 29 th August 2018 Review Date 7 th June 2021 Target Audience All directorates, clinical and managerial staff 1. KEY PRINCIPLES ABOUT THIS POLICY This policy provides a framework for the management of claims made against the Trust This policy has been reviewed and is compliant with the most up to date Code of Practice and NICE Guidelines Title of Code of Practice NICE Reference Number(s) General Data Protection Regulations 2018 Page 1 of 26

2 VERSION CONTROL LIST Version Date Author Status Comment February Amanda Approved Changes made to reflect 2015 Shaw changes in NHSR Processes February Matt Draft Changes in terminology, 2018 Mansbridge review of policy and update onto new template. 6.0 June 2018 Matt Mansbridge Approved Summary of Changes since Version 5 Numbers (Select the appropriate action) Page Paragraph Appendix Original/New/Amendment/Deleted Statement (select the appropriate action) New SABP Policy Template Change of terminology from Legal Services and Reporting Manager to Legal Services Team throughout document Change of terminology from NHSLA to NHSR throughout document Information added regarding GDPR Page 2 of 26

3 Contents Page Section Page POLICY SECTION Version Control List 1.0 Policy Purpose Policy Statement Related Policies Glossary of Terms References 5 PROCEDURE SECTION 6.0 Roles and Responsibilities Procedure Flow Chart Procedure Statement Start the Procedure/Process from this point Procedures for Handling Claims Trust Employees Learning Lessons from Claims Financial Management Claims Handling Reports Request from Clinicians from Legal Advice Monitoring Table 13 Equality Analysis 15 Appendix 1 Timescales Appendix 2 Procedure for dealing with claims under different schemes Appendix 3 Letters of Claim Appendix 4 Reporting Guidelines Page 3 of 26

4 POLICY SECTION 1.0 Purpose This policy and procedure provides the framework for the effective management of clinical negligence, third party liability and property claims. 2.0 Policy Statement Surrey and Borders Partnership NHS Foundation Trust is committed to an effective and timely investigation of and response to, any claims which include allegations of clinical negligence, third party liability or property claims. The policy and procedures apply to the management of the following types of claims: Clinical Negligence - covered by NHS Resolution (NHRS) Clinical Negligence Scheme for Trusts (CNST) Employer Liability (EL) - covered by the NHS Resolution (NHRS) Liability to Third Parties Scheme (LTPS) Public Liability (PL) (as above) Claims in respect of loss or damage to Trust property - covered by the NHSR Property Expenses Scheme (PES). Adherence to the policy and procedures should ensure: a) That Trust staff are clear about the process for managing claims, including their responsibilities in relation to this. b) That the Trust complies with the requirements for membership of the NHSR risk pooling schemes and also with the Civil Procedure Rules requirement of the Pre-action Protocol for the Resolution of Clinical Disputes and the Pre-action Protocol for Personal Injury, so avoiding the cost penalties associated with non-compliance. 3.0 Related SABP Policies This policy should be read in conjunction with the following policies; Incident Management Policy Inquest Management Policy Page 4 of 26

5 4.0 Glossary of Terms Claimant Any person who uses services or their representative, member of the public, or employee who instructs solicitors to act on their behalf to pursue a claim against the Trust, or who enters legal proceedings against the Trust or who pursues compensation. The on-going or future treatment of any person who uses our services will not be affected by making a claim against Our Trust, and the future experience of any staff member making a claim against Our Trust will similarly not be affected. Claim Where the context allows, any action against the Trust initiated by a claimant or any claim lodged by the Trust under the terms of the Property Expenses Scheme. Clinical Negligence Scheme for Trusts (CNST) The scheme, operated by NHSR, of which the Trust is a member, and which assumes liabilities for the appointment of solicitors and the settlement of all claims, in full, which are made against the Trust. Liabilities to Third Parties Scheme (LTPS) The scheme operated by NHSR, of which the Trust is a member, which assumes liability for the appointment of solicitors and (subject to member excess) the settlement of all claims which are made against the Trust. Legal Services Team The in-house legal team comprising of the Head of Legal Services and the Legal Services Manager. Property Expenses Scheme (PES) The scheme operated by NHSR, of which the Trust is a member, which assumes liability for the management and settlement of all claims made by the Trust in respect of premises and property. 5.0 References None Page 5 of 26

6 PROCEDURE SECTION 6.0 Roles and Responsibilities 6.1 The Director of Risk and Safety is responsible for ensuring That the arrangements for the management of claims are appropriate and complementary to the Trust s risk management programme That the management of claims is in line with the requirements set out by the NHS Resolution That the Trust Executive Board is informed of ongoing legal proceedings. For reporting annually to the Trust Board. 6.2 The Director of Finance is responsible for ensuring that there are sufficient provisions for managing the payment of membership fees and claims in accordance with Trust Standing Financial Instructions (SFIs) and ensure that there is sufficient oversight of the claims processes through the internal audit committee. 6.3 The Legal Services Team is responsible for managing the claims made under the NHSR risk pooling schemes and will ensure that the appropriate procedures are followed: Where a formal complaint is pursued under the NHS complaints procedure and where there is a demand for compensation. When there is a request for disclosure for records under the relevant Pre- Action Protocol indicating that the claimant is contemplating legal action against the Trust. When a letter of claim is received. Where legal proceedings have been entered against the Trust. The Legal Services Team will report claims to NHSR and undertake all associated administration and liaison with NHSR, Panel Solicitors, Trust officers, Claimants Solicitors and others as necessary. Page 6 of 26

7 6.4 Managers are responsible for investigating claims and obtaining the required documentation requested by the Legal Services Team in order to comply with any disclosure requirements. 6.5 All staff are responsible for co-operating with the Trust in the investigation and management of a claim and will be supported should their involvement be required at a later stage. Page 7 of 26

8 7.0 Procedure Flow Chart Claims Management Process Letter of claim received by SABP Letter of claim received by NHSR Uploaded to NHSR claims management system SABP informed via NHSR Claims management system Claim investigated by Legal Services Team with the assistance of the Service involved. Liability discussed between Legal Services Team and NHSR Claim defended Liability admitted, in full or in part. Page 8 of 26

9 8.0 Procedure Statement This procedure outlines the steps to be taken when notification of a claim is received and how the claims process is managed within the Trust. 9.0 Action on Receipt of a Claim All potential claims under any of the NHSR schemes should be forwarded immediately to: Legal Services Team Trust Headquarters 18 Mole Business Park, Randalls Road Leatherhead, Surrey, KT22 7AD The Legal Services Team will, as appropriate, submit the claim to NHSR in accordance with the rules of the relevant scheme (CNST, PES, LTPS). NHSR may appoint a Panel Firm of Solicitors to act on behalf of the Trust in the legal management of the claim. Any request for disclosure of medical records in relation to a claim should be forwarded to the Medical Records department.they will inform the Legal Services Team who will acknowledge the request. The Medical Records department will subsequently arrange for the required disclosure Procedures for Handling Claims The Legal Services Team will provide the following services on behalf of the Trust: On receipt of a request for disclosure of records which indicates that a clinical negligence claim is being contemplated, will in conjunction with Medical Records Department, obtain all medical records pertaining to the treatment in question, obtaining more information from the person who uses services or their solicitor if necessary. Contact appropriate clinicians. Disclose copy records in accordance with Trust policy. Receive, acknowledge and assess all new NHSR claims that arise against the Trust. Page 9 of 26

10 Set up and maintain a claim file. Notify the Employment Services Bureau of any new employers liability claim Notify the Finance department of all RPST claims and amount to be established in the provisions Establish an objective account of the original incident, giving appropriate weight to the recollection of the staff originally involved (this may already be available from Datix incident report forms) and the local investigations undertaken by managers. Identify and arrange for the preservation of all records and other items (eg equipment) related to the incident. Establish and as necessary maintain contact with all relevant staff and former staff. Provide support for staff involved in the litigation process. Undertake the initial preliminary analysis of clinical negligence claims on facts, liability, causation and quantum, where possible Report claims to NHSR under the appropriate scheme. Liaise with NHSR claims handlers during the course of the claim. Systematically review case files to ensure that claims are progressed and brought to a conclusion as swiftly as possible. Prepare reports for the Trust to include: 1. The number and value of claims and details of individual claims 2. The progress and likely outcome of these claims, including the expected settlement date 3. The final outcome of the claims 4. Any proposed remedial action arising out of a particular claim Notify all relevant staff when the claim is concluded NB NHSR is responsible for the overall determination of how a claim is handled within the relevant Scheme, and negotiation and authorisation of out-of-court settlements, but will take the views of the Trust into account. There may be occasions when the Trust may wish to make an ex-gratia payment without an Page 10 of 26

11 admission of liability. In these circumstances the claim is not within any NHSR Scheme and the Trust would not be able to recover any costs from the NHSR and would need to be satisfied that the CNST reporting guidelines had not been breached. Advice is available from the Legal Services Team Trust employees The full co-operation of all Trust staff is essential to ensure that the opportunity to defend any claim is maximised (or in the case of property and contents claims, fully documented and substantiated). Witness statements (and where appropriate, opinions) shall be sought and carefully considered. The Legal Services Team will provide general advice on statement writing and request statements from staff. In some cases, external solicitors will be involved in drafting statements. In respect of clinical negligence claims, the clinician with responsibility for the overall care of the claimant will be consulted prior to release of medical records to the claimant and/or their nominated solicitor. The clinician responsible for the on-going care of the patient shall be kept advised of the progress of the claim, including details of the claims resolution. Trust staff involved in a claim are encouraged to contact the Legal Services Team for information, advice or support on any claim related matter Learning lessons from Claims It is a vital part of the Organisation s response to a claim that lessons are learned and shared with staff. To this end, once a claim has been closed, a report will be produced, outlining a brief synopsis of the claim, details of the process with NHSR/Solicitor, and details of the resolution that has been reached. Lessons to be learned from the claim will be noted. The report will be shared with the Director for the relevant Service or delegated deputy, and team/ward area that the claim relates to. These reports will also be shared via the divisional Quality Page 11 of 26

12 Action Groups and the Quality, Risk and Safety Committee. Should the lessons learned identify that a change in practice/policy/procedure is required; changes will be made as appropriate Financial management Responsibility for the accounting and management of clinical negligence claims rests with NHSR (although the Trust retains legal responsibility for such claims). In respect of other legal claims such as personal injury and property losses, the Trust must make financial provision for the policy excess, associated damages and legal costs. In order to ensure the completeness and accuracy of Trust accounts, the Legal Services Team will liaise with the Finance Department of any claim lodged against the Trust and all claims made by the Trust in respect of Trust property, upon receipt (or submission). The current policy excesses are as follows: Scheme Excess Applicable CNST No excess Property Expenses Scheme Buildings - 20,000 Plant, machinery, contents 20,000 Liabilities to Third Parties Scheme Public liability - 3,000 Employer liability - 10,000 Product liability - 3,000 Professional indemnity - 3, Claims Handling Reports The Audit Committee will receive quarterly reports on: The number and aggregate value of claims and details of individual claims Page 12 of 26

13 The progress and likely outcome of these claims, including the expected settlement date The final outcome of the claims Any proposed remedial action arising out of a particular claim The Quality Committee will receive an annual report on the effectiveness of the claims management processes Request from Clinicians for Legal Advice Should clinicians feel they may require legal advice, they are advised to contact the Legal Services Team. Full information on the situation requiring clarification should be provided, including the clinician s contact details. The Legal Services Team may provide this advice, or may contact solicitors for further clarification and this will then be shared with the clinician. On occasions, the solicitors may communicate directly with the clinician following instruction from the Legal Services Team Monitoring Table What will be Monitored How/ Method Frequency Lead Reporting to (What Committee) Deficiencies / gaps recommendations and actions That duties outlined within policy are still relevant. Claims management process to include action taken and communication with stakeholders 3 Solicitors Risk Management Reports on claims Report Annual Director for Service or nominated deputy Review Annual Director for Service or nominated deputy Lessons learned report Annual Director for Service or nominated deputy Quality, Risk and Safety Committee Quality, Risk and Safety Committee Quality, Risk and Safety Committee If duties of nominated people change, policy to be amended to reflect Non-compliance will be reported to the relevant Director for Service or nominated deputy for them to take appropriate action Non-compliance will be reported to the relevant Director for Service or nominated deputy for them to take appropriate action Page 13 of 26

14 What will be Monitored How/ Method Frequency Lead Reporting to (What Committee) Deficiencies / gaps recommendations and actions Compliance with the policy. Report Annual Director for Service or nominated deputy Quality, Risk and Safety Committee Non-compliance will be reported to the relevant Director for Service or nominated deputy for them to take appropriate action Page 14 of 26

15 Equality Analysis - The equality analysis guidance notes and template are provided to support you in meeting the requirements of the Public Sector Equality Duty which came into force on 5 April You should use this template to record evidence that equality analysis has been carried out before policy decisions take place. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law. 1. About the policy/project/change Title of the policy / project / change: What are the intended outcomes / changes expected as a result of this policy / project / change: Are there links with other existing policies/projects: (if yes provide details) Claims Handling Policy Intended to support staff through the process of claims handling. No 2. Decide if the policy / project / change is equality relevant Does the policy/project involve, or have consequences for people using services, carers, employees or other people? If yes, please state the groups of people who are likely to be affected. If yes, then the policy/project is equality relevant. If no, you can skip to section 6. However the majority of Trust policies and projects are equality relevant because they affect people in some way. Yes 3. Gathering evidence to inform the equality analysis What evidence have you gathered to help inform this analysis? This can include evidence from national research, surveys & reports, interviews and focus groups, policy monitoring and evaluations from pilot projects, etc. If there are gaps in the evidence available under any of the characteristics, please explain why this is the case and state what actions will be taken to close the gaps as part of the action plan. Please ensure you check Annex C of the guidance notes for sources of evidence. Page 15 of 26

16 The Protected Characteristics & Evidence Using the relevant available evidence - what is known, understood or assumed about each of the equality groups / protected characteristics identified below that could be relevant to this policy / project / change. Record the sources of the evidence used for all the protected characteristics 4. Engagement and Involvement Record the names of the people and/or groups involved in gathering evidence and/or testing the evidence against the policy / project / change. Who and how were they involved? Who name of individual / group(s) represented Head of Legal Services How have these people been involved e.g. meeting Reviewing of the policy 5. Analysis of the potential impact of the policy / project / change Based on the evidence you have gathered; describe any actual or likely impacts that may arise as a result of the decision and whether these are likely to be positive or negative. Where actual or likely impacts are identified, you should also state what actions will be taken to promote the likelihood of positive impacts as well as minimise or mitigate against possible or likely negative impacts, i.e. what can the Trust reasonably do to actively manage the consequences of its decision / action Eliminate discrimination, harassment and victimisation: Does the policy / project / change, help eliminate discrimination, harassment and victimisation in any way? If yes, provide details. If no, provide reasons Age No evidence to believe that this group will be adversely affected by the use of this policy. Relevant to all people equally. Caring responsibilities No evidence to believe that this group will be adversely affected by the use of this policy. Relevant to all people equally. Disability No evidence to believe that this group will be adversely affected by the use of this policy. Relevant to all people equally. Gender reassignment No evidence to believe that this group will be adversely affected by the use of this policy. Relevant to all people equally. Marriage & civil No evidence to believe that this group will be adversely Page 16 of 26

17 partnerships Pregnancy & maternity Race / ethnicity Religion or belief Sex / gender Sexual Orientation affected by the use of this policy. Relevant to all people equally. No evidence to believe that this group will be adversely affected by the use of this policy. Relevant to all people equally. No evidence to believe that this group will be adversely affected by the use of this policy. Relevant to all people equally. No evidence to believe that this group will be adversely affected by the use of this policy. Relevant to all people equally. No evidence to believe that this group will be adversely affected by the use of this policy. Relevant to all people equally. No evidence to believe that this group will be adversely affected by the use of this policy. Relevant to all people equally. Advance equality of opportunity: Does the policy / project / change, help develop equality of opportunity in any way? This could include removing or minimising disadvantages suffered by people due to their protected characteristics, taking steps to meet the needs of people from protected groups where these are different from the needs of other people, or encouraging people from protected groups to participate in activities where their participation is disproportionately low. If yes, provide details. If no, provide reasons Age Caring responsibilities Disability Gender reassignment Pregnancy & maternity Race / ethnicity Religion or belief Sex / gender Sexual Orientation No-impact neutral No-impact neutral No-impact neutral No-impact neutral No-impact neutral No-impact neutral No-impact neutral No-impact neutral No-impact neutral Page 17 of 26

18 Promote good relations between different groups: Does the policy / project / change, help foster good or improved relations between different groups in any way? If yes, provide details. If no, provide reasons. Age The policy allows for a fair process in relation to Claims Handling. Caring responsibilities The policy allows for a fair process in relation to Claims Handling. Disability The policy allows for a fair process in relation to Claims Handling. Gender reassignment The policy allows for a fair process in relation to Claims Handling. Pregnancy & maternity The policy allows for a fair process in relation to Claims Handling. Race / ethnicity The policy allows for a fair process in relation to Claims Handling. Religion or belief The policy allows for a fair process in relation to Claims Handling. Sex / gender The policy allows for a fair process in relation to Claims Handling. Sexual Orientation The policy allows for a fair process in relation to Claims Handling. What do you consider the overall impact: Considering the combined impact of the analysis and the actions required to promote the likelihood of positive impacts and minimise or mitigate against potential negative outcomes does the analysis support the implementation of the policy / project / change? Yes because it ensures a fair process for Claims Handling. 6. Action Planning Actions to be taken as a result of this analysis (add additional rows as required): None Name of person who will take this action Date action due to be completed Page 18 of 26

19 7. Authorisation Name & job title of person completing this analysis: Date of completion: 23/05/2018 Name & job title of person responsible for monitoring and reporting on the implementation of the actions arising from this analysis: Name & job title of authorised person: (If there are doubts about the completeness or sufficiency of this equality analysis, seek advice from the Equality and Human Rights Team or the Legal Services & Reporting Manager in the Clinical Risk & Safety Team) Date of authorisation: 23/05/2018 Matt Mansbridge Legal Services Manager Katie Viggers Head of Legal Services Evonne Harding - Director of Risk and Safety Page 19 of 26

20 Appendix 1 TIMESCALES There are timescales relating to the period within which a claim should be brought the limitation period. For personal injury and clinical negligence claims the Claimant should issue their Claim Form through the Court within a period of 3 years of the date of incident which allegedly caused them harm or within 3 years of their date of knowledge if this can be proven to be later. The two main exceptions to this are: children (their 3 year period does not commence until they reach the age of 18), or people under a disability ie: of unsound mind who are incapable of managing their own affairs (such people may bring an action at any time whilst the disability exists). There are a number of timescale targets which apply to the claims management process. The Trust will aim to meet these targets where applicable: Provision of copy medical records under the Data Protection Act 2018 and the General Data Protection Regulation (collectively referred to as the Data Protection Legislation), the Access to Health Records Act 1990 (applies to deceased people who use services only) and the Pre-action Protocol for the Resolution of Clinical Disputes within one month of receiving a properly authorised request or within 21 days for deceased people who use services if the record has been added to within the 40 days preceding the receipt of the request or within 40 days otherwise. A. Reporting a potential clinical negligence claim to the NHSR within 2 months of receiving an indication of a claim. The Legal Services Team will need to obtain records, clinician s comments and produce a preliminary analysis prior to reporting. B. Reporting a potential employer/public liability claim to the NHSR Under the new Claims Portal, Employers Liability (EL) and Public Liability (PL) claims Page 20 of 26

21 are to be managed by a web-based portal process. All EL and PL claims valued up to up to 25,000 will be notified direct to the NHSR via the Portal. C. Acknowledging the claimant s solicitor s letter of claim 21 days D. Responding to the claimant s solicitor s letter of claim with a letter of response (with either an admission or denial of liability) 3 months after receipt of letter of claim. E. Acknowledging the service of formal proceedings (ie: the Claim Form, Particulars of Claim, Schedule of Damages) 14 days from receipt. F. Serving a Defence 28 days from receipt of proceedings. An extension may be applied for if, for example, the proceedings were incomplete or the claimant s solicitor has not complied with the Pre-action Protocol due to a limitation issue. Page 21 of 26

22 Appendix 2 PROCEDURES FOR DEALING WITH CLAIMS UNDER DIFFERENT SCHEMES A) Procedure for management of Existing Liabilities Scheme (ELS) cases ELS cases are those involving any clinical incident that occurred prior to 1 April 1995, where settlement was or will be made after 1 April All the existing cases were transferred for direct management to the NHSR in August Any new ELS cases (See flowchart, Appendix 4) received after that date will be fully investigated upon receipt and reported to the NHSR as follows: Claims with a value of more than 1m or which are novel, repercussive or contentious will be registered with the NHSR immediately following receipt of a letter of claim. All other claims will be registered with the NHSR when prior approval is required for a step, as detailed in NHSR C2/99 ELS Protocol and Standard Report Format, dated 1 April B) Procedure for management of Clinical Negligence Scheme for Trusts (CNST) cases, including requests for disclosure of records, serious clinical incidents and complaints CNST claims are those involving any clinical incident that occurred after 1 April These claims will be managed by Claims Managers in accordance with Reporting Claims to the NHSR, version 1.01 April 2014 and the Pre-Action Protocol published under the new Civil Procedure Rules in 1999 (see flowchart, Appendix 5). N.B. NHSR authorisation is required before admissions may be made and monetary compensation may be offered. In the absence of such authorisation, the NHSR will not reimburse Trusts either for the compensation awarded or for any of the costs generated. Any such payments made by a Trust will fall outside the scheme and could possibly result in criticism from auditors. In addition, the CNST reporting guidelines require Trusts to report the following events as Page 22 of 26

23 claims. The definition of a claim being allegation of clinical negligence and/or a demand for compensation made following an adverse clinical incident resulting in personal injury, or any clinical incident which carries significant litigation risk for the Trust : Those revealing a possible breach of duty leading to a potential large value claim (i.e. damages of over 250,000). These cases to be reported to the Legal Services Team who will prepare the preliminary analysis. Claims arising from a complaint investigation where the response, on the facts, indicates that an admission of liability has been implied. These cases to be reported to the Legal Services Team who will prepare the preliminary analysis. Requests for disclosure of records with no indication of a claim, where the preliminary analysis indicates the possibility of a claim with a significant litigation risk, regardless of value. C) Procedure for Management of Employee and Public Liability claims Legal Services Team will receive, assess and notify claims as follows: Incidents prior to Claim reported to commercial insurer who will investigate claim in conjunction with the Trust. Incidents after Employee and public liability claims reported to the NHSR Liabilities to Third Parties Scheme (LTPS). D) Procedure for Management of NHSR Property Expenses Scheme (PES) Claims The Legal Services Team will receive, assess and notify property claims covered by the NHSR s Property Expenses Scheme (PES) in conjunction with the relevant service managers, as detailed in the NHSR PES manual. The following claims will be reported to the Scheme: Page 23 of 26

24 All cases where the potential will exceed the excess (see section 7, Financial Management) Cases within 20% of the excess, regardless of whether the Trust wishes the NHSR to handle the claim on a sub-excess basis. Cases where the potential develops to the extent that the excess will be breached. Legal Services Team will work with the NHSR claims handler in investigating the claim and providing appropriate information and evidence as required. Page 24 of 26

25 LETTERS OF CLAIM Appendix 3 A formal letter of claim should include: A. The main allegations of negligence B. The injuries sustained C. The present condition and prognosis D. Any financial loss with an indication of the heads of damage Page 25 of 26

26 Reporting Guidelines Appendix 4 Reporting Guidelines have been issued by NHSR to assist with reporting of claims. It is recommended to work from the electronic version of the Reporting Guidelines as the Guidelines will change over time. Information contained includes: When should a claim be reported to the NHS LA What documents should be sent to the NHS LA when reporting a claim NB NHSR will be unable to consider requests for indemnity unless the relevant Claim Report form has been completed. Claim Report forms to be completed: Clinical Claim Report Form (if CNST claim) LTPS Claim Report Form (If LTPS claim) Inquest Funding Request Form. (NB-This form needs to be sent to NHSR in addition to the relevant scheme s Claim Report Form and Useful Documents Guide.) PES claim report form (If PES claim) Page 26 of 26