Unemployment Claim form

Transcription

1 Unemployment Claim form Section A Your details (To be completed by you) Title Surname Forename(s) Address Home Telephone Number Alternative Telephone Number Address Date of Birth Age Have you made any other insurance claims in respect of this Unemployment? If, please provide details to include policy number, name of company, address, contact telephone number and the type of policy you hold i.e, mortgage payment protection, loan protection etc. Office Use Only Policy reference Paymentshield Claims Administration PO Box 229, Southport PR9 9WU Tel: Fax: Paymentshield and the Shield logo are registered trade mark of Paymentshield Limited. Paymentshield Limited (registered number ) is a company registered in England and Wales at Paymentshield House, Southport Business Park, Wight Moss Way, Southport, PR8 4HQ. Paymentshield Limited, Authorised and regulated by the Financial Conduct Authority. Telephone calls to Paymentshield may be recorded for security purposes and monitored under our quality control procedures. Ref: PSL/5042/UC-F (01/14). CC4340.

2 Section B - Sharing information about your claim (to be completed by you) The details regarding your claim are considered to be private and cannot be disclosed to any other party without your express consent. This includes any other person named on the policy and any intermediary (e.g. financial advisor). If we are asked to do so, can we share information about your claim with the intermediary who introduced your policy to Paymentshield? If, please provide their full name and telephone number. Please note we cannot accept a company name. Name Telephone number If we are asked to do so, can we share information with any other person? If, please provide details of who we can share information with: Name Name Relationship to you Relationship to you Section C - Your financial details (To be completed by you) Please note: we may request sight of pay slips for both insured parties (where appropriate) to support our assessment of your claim. This will allow us to determine the benefit amount applied to your particular claim. Your gross annual income prior to your unemployment Lender name and address Start date of your mortgage Current monthly mortgage repayment Current monthly buildings cover premium Current monthly life/endowment cover premium Current monthly contents cover premium Is your cover provided by this policy split with any other person? If, who is the cover split with? Annual income of second named person Please provide your Bank Account details where you would like any claims funds credited to. Bank name Bank Sort Code Account Number Branch Name of account holder Section D - Important Information & Declaration (All applicants should read this section carefully and sign the declaration) We aim to provide an efficient and understanding claims service, however, making false, misleading or exaggerated insurance claims is a crime. We participate in the insurance industry action to keep premiums down to ensure that the honest policy is not subsidising fraudulent claims. Declaration - we are unable to start processing your claim without this signed declaration. Title Full Name I am presently unemployed and wish to claim benefit under the Terms and Conditions of my policy. I declare that the answers I have given are true and complete to the best of my knowledge and belief. I understand that if I knowingly give false or misleading information, or my claim is exaggerated, I will have to repay any benefits I have received. I also understand that I will lose all rights under the policy and that legal action could be taken against me. I understand that I must provide any evidence required by Paymentshield Limited, Aviva Insurance Limited and their representatives to prove my claim and must continue to do so during the period of any such claim. Insurers share information with each other to prevent fraudulent claims via a register of claims. 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 the register. I consent to the seeking of information from other insurers to check the answers I have provided, and I authorise the giving of such information I authorise Paymentshield Limited, Aviva Insurance Limited and their representatives to make any enquiries and obtain any information they consider relevant from my Employer, Previous Employer, Mortgage Lender, Department for Work and Pensions and H M Revenue & Customs. A photocopy of this authorisation shall be considered as effective and valid as the original. DATA PROTECTION DECLARATION: I have read and understood the data protection information in the attached leaflet headed Unemployment Claim Support Information Signature Date

3 Section E - Employment details (Complete this section if your last work was on an employed basis) Name of last employer Address of last employer Telephone Number Occupation prior to unemployment Fax Number Contracted hours worked per week Employment Terms (please tick appropriate box) Permanent Full Time Permanent Part Time Fixed Term Contract Temporary Seasonal Date employment commenced Date employment ended What was the reason for your unemployment Have you obtained a new job? If, when did your new job start? Contracted hours worked per week Employment Terms (please tick appropriate box) Permanent Full Time Permanent Part Time Fixed Term Contract Temporary Seasonal Section F - Self-employment statement (Complete this section if your last work was on a self-employed basis) Nature of business Trading name Trading address Business Telephone Number Business Fax Number Are you a CIS card holder? If, please provide a copy of your CIS card or alternatively correspondence from H M Revenue & Customs confirming your CIS card number along with confirmation from H M Revenue & Customs that you have de-registered with them. Date trading commenced Date you last worked Date you returned to work (if applicable) Minimum hours worked per week hours What was the reason for your unemployment Have you been contracted to the same employer for more than 2 years If, please give details Have you totally and permanently ceased trading? (If, please provide evidence of cessation from H M Revenue & Customs) If, please give details Your business accountant s name Accountant s Address Please note: If you have been employed or self employed for less than 6 months please provide details of your employment covering the previous 6 month period over leaf in Section G, along with evidence of your employment where possible. This can be in the form of a contract of employment, payslips, severance letter, P45 etc.

4 Section G - Employment Information Questionnaire Name and Address of Employer Date Employment Commenced Date Employment Ended Hours Worked Per Week Terms of Employment (i.e. permanent, temporary, fixed term contract (please confirm dates of any contracts)) Reason for Leaving Name and Address of Employer Date Employment Commenced Date Employment Ended Hours Worked Per Week Terms of Employment (i.e. permanent, temporary, fixed term contract (please confirm dates of any contracts)) Reason for Leaving Name and Address of Employer Date Employment Commenced Date Employment Ended Hours Worked Per Week Terms of Employment (i.e. permanent, temporary, fixed term contract (please confirm dates of any contracts)) Reason for Leaving

5 Section H - Employers/Liquidators Certificate (This section needs to be completed by your previous employer or the liquidator responsible) Full name of Employee Date of Birth Staff Number Full Address of Employee Occupation If the employee was a director, were they a controlling/shareholding director in the business? What was the reason for termination of employment? (please tick appropriate box) Dismissal End of Contract Redundancy Laid Off Cessation of Company Completion of Government Training Scheme Completion of Apprenticeship Resignation Retirement Other, please specify If dismissal, please provide full details Date employment commenced with your company Date first notified of unemployment either verbally or in writing Date last worked Contracted hours worked per week Employment Terms (please tick appropriate box) Permanent Full Time Permanent Part Time Fixed Term Contract Temporary Seasonal If Fixed Term Contract, please provide the details of all contracts with your company and the dates the contracts were to run from and to Was the employee given any prior indication that his or her employment with your company may be at risk? If, please provide details and the dates of any general notifications and official notifications Have you offered payment instead of notice or compensation for loss of office? If, please provide details of notice period received and period payment covers Days From To Have you ever employed this person before? If, please provide dates of employment and reason for termination From To Dismissal End of Contract Redundancy Laid Off Cessation of Company Completion of Government Training Scheme Completion of Apprenticeship Resignation Retirement Other, please specify If dismissal, please provide full details Signature OFFICIAL STAMP Position Date Name in BLOCK CAPITALS Please note: If you do not have an offical stamp, please enclose a signed company compliment slip or letter head.

6 Section I - Confirmation of Unemployment Certificate Please complete ALL PARTS of this form PART I - CLAIMANTS DETAILS First name(s) Last name Date of Birth Daytime telephone number PART 2 - JOB SEEKERS AGREEMENT Do you have a Job Seekers Agreement with the Department for Work and Pensions? Please enclose a copy of the Job Seekers Allowance Decision Letter. Please note that we will not be be able to consider your claim without this document. Please give details why PART 3 -JOB SEARCH INFORMATION Since becoming unemployed, have you been continuously available for work AND actively seeking employment of at least 16 hours per week? If no please specify why overleaf Are you registered with any job clubs / employment agencies? If yes please provide details overleaf Are you attending any training or educational courses? If yes please provide details overleaf IMPORTANT: Please complete the table overleaf headed 'IMPORTANT INFORMATION', confirming details of your job search activity. For each month that you have been unemployed you must complete details of at least 3 positions you have applied for. AND Please attach copies of application and response letters to support the details completed in the table. PART 4 - CURRENT STATUS Have you completed any work either paid or unpaid since you became unemployed? If yes please provide details overleaf Do you currently have any job offers? If yes please provide details overleaf Have you started, or are about to start, a new job? If yes please enter start date Please enclose a copy of the job offer letter and your P45 from the Department for Work and Pensions PART 4 - CURRENT STATUS I declare that the answers I have provided on this certificate are true and complete to the best of my knowledge and honest belief. I confirm that I have disclosed to you any work I have undertaken, either paid or unpaid, since the commencement of this or any other current claim. I am aware that if I knowingly give incorrect information I will lose all rights under the policy, I will have to repay any benefit I have received and legal action could be taken against me. I authorise the Department of Work and Pensions (DWP), Her Majesty's Revenue and Customs (HMRC), Recruitment Agencies and any other relevant parties to release, on request by Paymentshield Limited and Aviva, information that is relevant to my claim. Claimants Signature Date

7 IMPORTANT INFORMATION Position applied for Name of company Address of company Telephone Number Date of Application ADDITIONAL INFORMATION

8 Section J Please use this section to give further information you think would be helpful in the processing of your claim