Claim notification form: Low value personal injury claims in employers' liability - disease (£1,000 - £25,000)
| Published date | 21 March 2018 |
Claim notication form (ELD1)
Low value personal injury claims in
employers’ liability - disease (£1,000 - £25,000)
Claimant’s representative - contact details
Name
Address
Contact name
Telephone number
E-mail address
Reference number
Defendant’s details
Defendant’s name
Defendant’s address*
Policy number reference (If not known insert not known)
Insurer/Compensator name (if known)
Date sent/ /
Postcode
Before lling in this form you are encouraged to seek independent legal advice.
Postcode
Items marked with (*) are optional and the claimant must make a reasonable attempt to complete those boxes.
All other boxes on the form are mandatory and must be completed before being sent.
Please tick here if you are not legally represented?If you are not legally represented please put your details in the
claimant’s representative section.
What is the value of your claim?up to £10,000up to £25,000
ELD1 Claim notication form (04.13)
This is a formal claim
against you, which must
be acknowledged by
email immediately and
passed to your insurer.
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