Carers Unemployment Claim Form Section A Your details (To be completed by your) Title Surname Forename(s) Address Home Telephone Number Alternative Telephone Number Email Address Date of Birth Have you made any other insurance claims in respect of this Unemployment? Age 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. Please return all of the information noted in Section E along with your fully completed claim form for us to fully assess your claim. If you return your claim form without the required information we will not be able to provide you with a decision on your claim until this is received. Office Use Only Policy reference Please return this form by either email to: claims@paymentshield.co.uk Tel: 0345 6011 060 Or by post to: Claims Team Paymentshield House PO BOX 229 Fax: 0345 6011 080 Paymentshield and the Shield logo are registered trade mark of Paymentshield Limited. Paymentshield Limited, 2016. 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. Paymentshield Limited (registered number 02728936) is a company registered in England and Wales at Paymentshield House, Southport Business Park, Wight Moss Way, Southport, PR8 4HQ. Ref: Asset 00486 (06/16)
Section B Important Information & Declaration (to be completed by you) 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 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, Covéa Insurance 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, Covéa Insurance 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 below. Signature Date Data Protection Information Sharing your personal information 1.We Paymentshield, are the insurance administrator for your policy. Our company number is 2728936 registered office: Paymentshield, Paymentshield House, Southport Business Park, Wight Moss Way, Southport, PR8 4HQ. For the purposes of the Data Protection legislation we are the Data Controller. 2. Your personal data, including any sensitive personal data as determined under the Data Protection Act 1998, will be held by us on a database. For example your name, address, date of birth, marital status, family details, employment details, financial details and medical details. The database is an electronic computerised database held on our computers at our office. We may also hold your personal information in a paper based filing system. 3. Your information comprises of all the details we hold about you, your transactions, and includes information obtained from third parties. 4. We may use and share your information to help us: Deal with any claim you make on your insurance policy To detect and prevent fraud we may: Share information about you with other organisations and public bodies including the Police Undertake credit searches and additional fraud searches Check and/or file your details with fraud prevention agencies and databases and if you give us false or inaccurate information and we suspect fraud, we will record this. 6. Other than purposes outlined in paragraphs 4 and 5 above, we will not pass your information to any other person, firm, company or organisation. 7. Your information may also be used for research and statistical purposes and also crime prevention. This information may be transferred to other countries, including some outside the European Economic Area. In such instances any we will ensure it is kept secure and on the basis that anyone we pass it to provide an adequate level of protection 8. We will keep your information for as long as you hold an insurance policy through us and for a reasonable period thereafter. 9. Access to your information: If you believe the information either we or the insurer hold about you is inaccurate, or you wish to receive a copy of the information we hold about you, please write to: The Data Protection Officer, Paymentshield Ltd, PO Box 229, Southport, PR8 9WU. Where copies of information are requested a fee of 10 will be charged, which must be paid before any information is sent. 5. We or your insurer underwriter may pass/share your information with third parties for the following purposes: To help us/the insurer to make decisions on your claim; If we have your consent; If we are permitted to do so by law; For the purposes of fraud prevention; If we transfer our agreement with you or any insurance policy we hold for you to a third party.
Section C Sharing information about your claim 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 Section other person B - Important named Information on the policy & and Declaration any intermediary (to be completed (e.g. financial by you) 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 (we require this information for Data Protection when they call): Name Date of birth Relationship to you Name Date of birth Relationship to you Section D Your financial details (to be completed by you) Please note: we may request evidence of income 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 declared annual income for tax purposes for the last financial year 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 E - Important information needed with your claim. A copy of the letter from the Department of Work & Pensions confirming your entitlement to Carer s Allowance. Please note, we will not be able to consider your claim without this document. Medical evidence in respect of the person requiring your care from their qualified medical professional; Fully completed continuing claim forms with copies of bank statements showing ongoing receipt of Carer s Allowance. All the below information is required from Employed Customers along with the information shown immediately above. A copy of your latest P60 or 6 months worth of payslips confirming the income on which you pay tax. All the below information is required from Self Employed Customers along with the information shown in the first 3 points. A copy of your latest Self Assessment Tax Calculations that you submitted to the HMRC. This must show the amount you have declared as Net Profit for tax purposes. Copies of correspondence, invoices and accounts from the time immediately prior to your claim date to show you were working at least 16 hours per week immediately before your unemployment.
Section F Employed (to be completed by you) Name of last employer Address of last employer Telephone Number Occupation prior to unemployment Employment Terms (please tick appropriate box) Permanent Full Time Permanent Part Time Fixed Term Contract Temporary Seasonal Date employment commenced What was the reason for your unemployment Have you obtained a new job? If, when did your new job start? Employment Terms (please tick appropriate box) Contracted hours worked per week Permanent Full Time Permanent Part Time Fixed Term Contract Temporary Seasonal Section G - Self Employed (to be completed by you) Trading Name & Address Business Telephone Number Date trading commenced Were you working a minimum of 16 hours per week every week prior to your unemployment? If, please provide a reason for this below: What is the reason for your unemployment? Have you totally and permanently ceased trading? If, please provide details as to why Are you in receipt of any remuneration from this business? If, please confirm details Do you still participate in anyway in the business? If, please confirm details Your business accountant s name Accountant s address
Section H - Employers Section (to be completed by your employer) Name of Employee Address of Employee of Employee Employee Date of Birth Staff Number Is the employee a controlling/shareholding director within the business? What was the reason for termination of employment? (please tick appropriate box) Dismissal End of Contract Voluntary Redundancy Compulsory Redundancy Laid Off Cessation of Company Resignation to become dependant carer Retirement Gross misconduct If Other, please specify If dismissal or gross misconduct, please provide full details Date employment commenced Date first notified of unemployment either verbally or in writing Date employee last worked for the company Contracted hours worked per week Employment Terms (please tick appropriate box) Permanent Full Time Permanent Part Time Fixed Term Contract Temporary Seasonal Did the employee work their full required notice period? If, please confirm the period this covered? From To Was the employee paid instead of working their notice? If, please confirm the period this payment covered? From To Please provide details and the date of any general notifications and or official notification of the employment ending prior to the customers resignation? Full Name Name and Address of company OFFICIAL STAMP Telephone Number Fax Number Contact E-mail Address Signature Date Position (to be completed by Line Manager/Personnel/Director/Owner Please note: If you do not have an official stamp, please enclose a signed company compliment slip or letter head.
Section I - Confirmation of Unemployment Certificate PLEASE COMPLETE ALL PARTS ON THIS FORM First name(s) Last name Date of Birth Address Do you have a Carers Allowance claim with the Department of Work and Pensions? Please enclose a copy of the Carers Allowance Decision Letter. Please note that we will not be be able to consider your claim without this document Please give details why below. Please confirm who you are now providing care for and their relationship to you Please provide details of the reasons the above person is now requiring full time carer Has this person been receiving care prior to you becoming their full time carer. If, please provide details below When did you first become aware that the above person required care? I declare that the answers I have provided on this certificate are true and to the best of my knowledge and honest belief. 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 Pension (DWP), Her Majesty s Revenue and Customers (HMRC) and any other relevant parties to release, on request by Paymentshield Limited and Covea, information that is relevant to my claim. Claimants Signature Date
Section J Please use this section to give further information you think would be helpful in the processing of your claim