Miles Smith Early Intervention Scheme (EIS) Claim Form

Company details

1. Referrer company name *

2. Referrer name *

Prefix First Name Last Name

3. Referrer job title *

4. Referrer address *

Street Address
Street Address Line 2
Town / City	County
Post Code	Country

5. E-mail confirmation *

Confirmation Email

6. Referrer telephone *

Area Code Phone Number

7. Claimant name *

Prefix First Name Last Name

8. Claimant Date of Birth *

Day Month Year

9. Claimant job title *

10. Claimant address *

Street Address
Street Address Line 2
Town / City	County
Postcode	Country

11. Claimant email address

Confirmation Email

12. Claimant telephone *

Area Code Phone Number

13. Claimant mobile

14. Please select one of the following options *

14.1 Is the absence a result of an incident which occurred whilst at work? *

Yes No Unsure

14.2 What was the date of the first day of absence? *

Day Month Year Date Picker Icon

14.3 Please select one of the following options *

14.4 Where is the injury? *

14.1 Where was the motor accident reported? *

The motor accident was reported to a police station The motor accident was reported to an insurance company

14.2 Name of the police station or insurance company *

14.3 What was the accident reference or claims reference number? *

14.4 What was the date of the motor accident? *

Day Month Year Date Picker Icon

14.5 Please select one of the following options *

14.6 Where is the injury? *

Unfortunately, we are unable to process the claim because the claimant has not been absent from work for at least three consecutive working days, nor involved in a reported motor accident.

I confirm that to the best of my knowledge that all of the information I have supplied is true and complete. *

Confirmed

I confirm that the claimant has given their informed consent for their personal details to be passed to, and processed as required under the policy terms and conditions, by Miles Smith Limited and their agents. *

Confirmed

Thank you for completing the claim notification form.

If, once you have submitted the form, you have not had an email acknowledging receipt of the claim within 4 hours (between 09.00 to 17.00, Monday - Friday), please call the EIS claims administrators at Miles Smith on 020 7977 4800. Claims submitted after 13.00 may be acknowledged the next working day.

So that we know you are human, please type the message in the box below *

Claimant Details

Claim Details

Declaration