Make a group income protection claim online

Is the employee absent from work?

Yes
No

Absence start date

Please enter the date in the format dd/mm/yyyy

Reason for the absence

Have there been any other absences in the last 12 months?

Yes
No

Please provide the date and reason for each absence

Please specify any treatment undertaken to date

Have they worked in any capacity since the first date of absence?

Yes
No

Please provide full details and dates

Annual salary at start of absence

Is the employee on a fixed term contract?

Yes
No

As of the initial date of absence, please confirm when their fixed term contract will cease

If applicable, when does their full company sick pay cease?

Please enter in the format: DD/MM/YYYY.

If non-applicable, please put: N/A.

If applicable, when does any additional partial sick pay cease?

Please enter in the format: DD/MM/YYYY.

If non-applicable, please put: N/A.

Please state the reason for the current referral

Have there been any absences in the last 12 months for the same reason?

Yes
No

Please provide the date and reason for each absence

Please specify any treatment undertaken to date

Has there been any occupational health involvement to date?

Yes
No

Have any adjustments been made to support the employee in their current role (e.g. additional software, ergonomic assessment, change in duties, etc)?

Yes
No

Please provide additional information

Are there any performance, disciplinary and/or grievance issues?

Yes
No

Please provide additional information

Do you consent to us contacting the employee?

Yes
No

Are we able to share information regarding the policy with the employee?

Yes
No

Make an Income Protection claim for an employee

Employee details

Need a copy of what you’re sending?

If you would like to save a copy of this form for your records, you can right click and print to PDF before you hit submit

Make a Group Income Protection claim online

Make an Income Protection claim for an employee

Employee details

Need a copy of what you’re sending?

If you would like to save a copy of this form for your records, you can right click and print to PDF before you hit submit

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