CARERS UNEMPLOYMENT CLAIM FORM C Piacle House, A1 Baret ay, Borehamwood, Hertfordshire D6 2XX Compay Number 1007798 IMPORTANT POLICY TERMS MAY VARY, BUT YOU SHOULD RETURN THE CLAIM FORM AS SOON AS YOU STOP ORKING. THIS ILL ASSIST THE PROMPT PROCESSING OF YOUR CLAIM Your copy of the Group Policy documet will tell you whether you ca make a claim Make sure you aswer all the questios o this form, otherwise it will delay your claim Our represetative might have to call o you while we are lookig ito your claim e eed evidece from the Departmet of ork ad Pesios that you have bee appoited a carer ad are i receipt of carers allowace for a member of your immediate family Make sure that the declaratio is siged before returig this form INSURANCE FRAUD IS A CRIMINAL OFFENCE - E RESERVE THE RIGHT TO REFER CASES TO THE APPROPRIATE AUTHORITIES A - Your Policy Details Please idicate what your policy relates to: (a) Mortgage (b) LoaFiace (c) Credit Card (d) Icome Protectio (e) Premium aiver FOR SECURITY REASONS, IF YOUR POLICY RELATES TO CREDIT CARD COVER, PLEASE DO NOT PROVIDE YOUR CREDIT CARD NUMBER AS THE POLICY NUMBER Policy Number Name of Policy Provider If you have aswered (a)-(c) above, please provide the followig: Name of Leder, if differet to Policy Provider B - Your Persoal Details Title First Name Mr Mrs Miss Ms Other of birth Address I order to give you the best possible service, we may use your mobile umber to call or text you ador your e-mail address to sed you updates o the progress of your claim. Please be assured either will be used for ay sales or marketig purposes or passed to ay other party without your specific coset. Should you NOT wish to be set updates through either of these methods, please tick the relevat box: SMS text E-mail Telephoe Mobile E-mail Address Natioal Isurace Number (NI) You ca fid this o: NI Card, payslips, letters from HM Reveue & Customs or from your Social Security Office C - Your Bakig Details Accout Holder Sort Code - - Bak Name Accout Number (Please complete this sectio ad if your policy allows us to pay direct to your bak, we will do so. PLEASE NOTE we ca ot pay i to a savigs accout.) D - About the perso you are carig for (Please provide details of the perso you are carig for) 1. Name of the perso you are carig for 2. to yourself 3. of birth of your family member 4. Are you i receipt of Carers Allowace? 5. If YES, please cofirm the date this commeced 6. hat is the ature of their disabilitycoditio? 7. hich beefit is your immediate family member i receipt of? Disability Livig Allowace Attedace Allowace Costat Attedace Allowace 8. Please cofirm the date this beefit commeced 9. of oset of their disabilitycoditio? e eed evidece from the Departmet of ork ad Pesios that you have bee appoited a carer ad are i receipt of carers allowace for a member of your immediate family e eed evidece from the Departmet of ork ad Pesios showig the date Disability Livig Allowace, Attedace Allowace or Costat Attedace Allowace commeced P2640v11-1392017
Em E - Your ork Details Please tick the descriptio that applies to you: orkig for a employer (Sectios E ad F to be completed) Self-employed (Sectios G ad H to be completed) D Na Name of your Employer Address of your Employer Te Telephoe Number of your Employer Email Address of your Employer (if kow) hat was your job title? hat was your ork or Staff Number? hat were your duties? F - Employer s Certificate he did you start workig there? How may hours a week did you work? HRS hat date did your employmet ed? If you have multiple jobs, please provide the ames ad addresses of all your Employers, icludig the hours worked per week, o a separate piece of paper securely attached to this claim form. PLEASE ASK YOUR LAST EMPLOYER TO COMPLETE THIS SECTION Compay Name C O M P L E T E D B Y L A S T E M P L O Y E R Compay Address C O M P L E T E D B Y L A S T E M P L O Y E R Telephoe Number L A S T E M P L O Y E R E-mail address C O M P L E T E D B Y L A S T E M P L O Y E R 1. Please cofirm the full ame of the perso who worked for you 2. hat date did the Employee start workig for you? 3. hat date did the Employee last work for you? 4. How may hours per week did the Employee work? HRS TO BE 8. If YES, how may times has this cotract bee reewed? (please give dates) LAST EMPLOYER 5. as the employmet: (please tick relevat optio) Permaet 6. If the Employee was employed From o a fixed-term cotract, what were the dates of the cotract? 7. If the Employee was employed o a fixed-term cotract, could they reasoably have expected you to reew it? To Temporary Cotract Seasoal 9. hat date did the Employee otify you of their itetio to resig? (hether verbal or writte) 10. hat reaso did the employee give for their resigatio? LAST EMPLOYER 11. hat was the Employee s Gross Yearly Salary at the time they left? Your Name Positio Sigature Compay Stamp (if Stamp ot available, please attach a SIGNED complimet slip) OMISSIONS ILL DELAY YOUR CLAIM EVIDENCE OF STAMP OR COMPLIMENT SLIP MUST BE PROVIDED TO VALIDATE THE CLAIM COMPLIMENT SLIP MUST BE SIGNED
G - Your Self Employmet Details hat date did you start workig o a Self Employed basis? hat date did you last work? Address of your Accoutat How may hours per week did you work? HRS hat was your occupatio? Name of your Accoutat Accoutat Telephoe Number Accoutat s E-mail address H - Accoutat s Certificate AS YOU ARE SELF EMPLOYED, PLEASE ASK YOUR TO COMPLETE THIS SECTION 1. hat was the Tradig Name of your Cliet s Compay? C O M P L E T E D B Y Y O U R A C C O U N T A N T 2. hat was the ature of your Cliet s busiess? 3. hat was the address your Cliet traded from? 11. Has HM Reveue & Customs ackowledged Cessatio of Tradig? 12. Has your Cliet or their Compay filed for bakruptcy or Liquidatio? 13. If YES, o what date? 14. Is your Cliet registered for VAT? 15. If YES, please provide their VAT Office details (NameAddress) 4. Did your cliet ow their ow busiess? 5. If NO, were they employed as a Sub-Cotractor? 6. hat date did your Cliet s self-employmet start? 7. hat date did your Cliet s self-employmet ed? 8. as your Cliet s self-employmet cotiuous for this period? 9. as the Compay a Limited Compay? 16. hat is the reaso for Termiatio of self-employmet? If YES, what percetage of shareholdig did your cliet have? % 10. hat date were HM Reveue & Customs iformed of Cessatio of Tradig? 17. VAT Registratio Number Your Name Positio Sigature COMPLETED BY YOUR COMPLETED BY YOUR COMPLETED BY YOUR Compay Stamp (if Stamp ot available, please attach a SIGNED complimet slip) OMISSIONS ILL DELAY YOUR CLAIM EVIDENCE OF STAMP OR COMPLIMENT SLIP MUST BE PROVIDED TO VALIDATE THE CLAIM COMPLIMENT SLIP MUST BE SIGNED E-mail address C O M P L E T E D B Y Y O U R A C C O U N T A N T IF YOU DO NOT HAVE AN, PLEASE PROVIDE COPIES OF THE DOCUMENTS REQUESTED BELO Last two years Tradig Accouts or evidece of the last two years Gross Icome. If ot available, please cofirm why. Cessatio of Tradig Accouts plus ay HM Reveue & Customs ackowledgemet letters. Last six moths Tradig Bak Statemets.
I - Data Protectio Except as authorised i the declaratio below, Cardif Piacle will ot discuss your claim with ayoe else without your permissio. This icludes your spouse, ay other relative or fried, or your legal advisor. If you wat to give us permissio to talk to aother perso, you ca authorise up to 3 people. Please provide their details below. Please ote that for your security, we will ask your authorised perso to cofirm their idetity by cofirmig YOUR full ame ad first lie of YOUR address ad YOUR security password. Security e will ask you for this password whe you or your represetative calls Password J - Declaratio ad Authority If you are claimig or itedig to claim with ay other isurer for your preset uemploymet, the please give details of the Isurer, Policy Number ad Claim Number: Isurer Details Policy Number Claim Number If you have made ay previous claims agaist this policy, the please give details: I declare that I have become a carer as defied i the policy ad have ot bee workig i ay capacity or doig paid work durig the period give. I declare that the statemets I have made are true ad agree that if they are foud to be utrue Cardif Piacle will have the right to reclaim all claim paymets made to me as a result of my dishoesty (i accordace with the policy wordig). I authorise Cardif Piacle ad ay of its agets to make ay equiries ad obtai ay iformatio they may cosider relevat from me, my last or previous employer(s), ay Govermet Body, other isurers ad licesed Credit Referece Agecies who may create a record of our search. I uderstad that my persoal iformatio will be held o computer or other files by Cardif Piacle or its agets for the purposes of admiisterig this isurace, icludig carryig out customer surveys, claims hadlig ad fraud prevetio. I agree to my persoal iformatio beig disclosed to the agetparty resposible for the sale of this isurace policy. Cardif Piacle will ot disclose your medical iformatio to the sellig agetparty without your coset. I uderstad it is my resposibility to give all ecessary iformatio to the Tax Authorities ad to meet ay tax demads I may have from my claim beig paid. Sigature Prit Name YOUR SIGNATURE PLEASE PRINT YOUR FULL NAME hat to do ow Make sure that (please tick ): you have aswered all the questios o the form that apply to you you have siged the form you have read the eclosed Claims Guide you esure that your Employer has completed Sectio F, or your Accoutat has completed Sectio H you have set us evidece from the Departmet of ork ad Pesios to state that you have bee appoited a carer ad are i receipt of carers allowace for a member of your immediate family you have set us evidece from the Departmet of ork ad Pesios showig the date Disability Livig Allowace, Attedace Allowace or Costat Attedace Allowace commeced if you have multiple jobs, you have provided the ames ad addresses of all your employers, icludig the hours worked per week o a separate piece of paper, ad securely attached it to this claim form please check the form ad esure that your employers have stamped or attached a siged complimet slip if you are satisfied with the cotet of this form, please read, sig ad date the declaratio ad authority above Policy terms may vary, but you should retur your claim form as soo as you stop workig Sed everythig to: Claims Departmet Cardif Piacle Piacle House A1 Baret ay Borehamwood Hertfordshire D6 2XX At Cardif Piacle, we are committed to providig you with the support you eed. Visit our support site for more details: www.support.cardifpiacle.com IMPORTANT: PLEASE BE AARE THAT ANY CALLS YOU MAKE TO US MAY BE RECORDED FOR TRAINING AND MONITORING PURPOSES Cardif Piacle is a tradig style of Piacle Isurace plc
CARERS I order to help you uderstad the process after you have submitted your claim, we have provided some frequetly asked questios ad aswers that you may fid useful: CLAIMS GUIDE here do I fid my policy umber? This will deped upo the type of policy you hold but i most cases your policy umber will appear o ay letters we have previously set you. However, if you o loger have ay of these letters your policy umber should be foud i the fulfilmet documets you received whe you first took your policy out. If you are uable to locate these the please esure you provide all other requested iformatio regardig your policy to allow us to locate it. Should your policy relate to Credit Card cover please DO NOT provide your credit card umber as the policy umber. How log will I have to wait for a reply after I have retured my claim form? If we hold your policy o our system, we aim to actio a fully completed claim form withi three workig days of receipt. If all the iformatio has bee provided we will write to iform you of our decisio. If we are uable to make a decisio based o the iformatio supplied, we will sed you a writte request for ay further iformatio required, or advise you of whom we have eeded to cotact to proceed. Either way, you should hear from us withi 10 workig days of submittig your claim. hy do you eed my mobile umber? e wat to make your claimig experiece as easy as possible therefore, if you do have a successful claim ad you have provided your mobile umber, we will sed you a text cofirmig paymet. hat evidece do I eed to supply? e eed evidece from the Departmet of ork ad Pesios that you have bee appoited a carer ad you are i receipt of carers allowace for a member of your immediate family. e eed evidece from the Departmet of ork ad Pesios showig the date Disability Livig Allowace, Attedace Allowace or Costat Attedace Allowace commeced. hy would it be ecessary to request further iformatio, if I have already set you a fully completed claim form? Sometimes we eed to obtai more specific iformatio that was ot detailed o the claim form. Below are two examples of whe it would be ecessary to write for further iformatio: Your employers have ot cofirmed the reaso you termiated your employmet. Cofirmatio from the Departmet of ork & Pesios that you have bee appoited a carer ad you are i receipt of carers allowace for a member of your immediate family. If we do eed further iformatio we will let you kow what is required as soo as possible to miimise the delay i processig your claim. If the iformatio we have requested is ot immediately forthcomig, we will chase all third parties for a respose after 14 days, thereafter two further chases will be set. e will keep you fully iformed of our progress. Is it importat that I check the iformatio provided by ay third parties who complete my claim form?, it is vitally importat that you check the iformatio o your claim form provided by third parties e.g. your employer, as these details will be used whe we assess your claim. Ay iaccuracies may result i your claim beig declied uecessarily, although you do have the right to appeal through our appeal procedures. Is it importat that my employers stamp the claim form with their official compay stamp?, it is importat that your employers have stamped their sectio of the claim form, by doig this they are verifyig the iformatio they have provided. If your employers do ot have a compay stamp, please ask them to sig a complimet slip cofirmig o stamp available ad retur this with your claim form. Is it possible that my claim will ot be accepted?, it is possible. A example of a commo exclusio uder carers cover is that the perso who you are carig for is ot a member of your immediate family (please refer to your policy documet regardig defiitio of immediate family). How will I be otified that my paymet has bee made? A letter will be set to you to otify you oce a paymet has bee made o your claim. If you have supplied us with your mobile umber, a text message will also be set to you o the day that the paymet has bee made to otify you. hat to do if you retur to permaet employmet? Please call us to cofirm the date you retured to work ad we will advise whether ay paymets are due. e will eed cofirmatio from the departmet of work ad pesios showig the date your Carers Allowace ceased. How log before paymet is made? Oce received, ad providig the form is fully completed ad all documetatio attached, we aim to make paymet o your claim withi three workig days. If you have provided your mobile umber, we will text you oce the paymet has bee released. Please be aware that paymets may take up to five days to reach your accout. Page 1 P2640v9 GUIDE