Wokingham Borough Council

Supply Insurance Scheme Claim Form

Ancillary Staff

Name of School:______

CostCentre: ______Subjective:______

Name of absent member of staff: Mr/Mrs/Miss/Ms/Dr ______

What is the absent staff member’s job title? ______

Is the teacher MALE or FEMALE? (Please circle as applicable)

For which month is this claim being made? ______

Does this claim arise from an ACCIDENT or from ILLNESS? (Please circle as applicable)

  1. On which days does the absent member of staffusually work? MON/TUES/WED/THUR/FRI (Please circle as applicable)
  1. What are the Full Time Equivalent hours of this member of staff? (Full time = 100%; 0.2 = 20%) _ _ _ %
  1. What is the specific reason for the staff member’s absence? ______(Please give full, clear details of the accident or illness.)
  1. On what date did the member of staff’s absence commence? ______
  1. Has the staff member previously suffered from any similar condition? Yes / No (Please circle as applicable)
  1. If yes, when was this? ______
  1. Is this a CONTINUING CLAIM FROM LAST MONTH or a NEW CLAIM? (Please circle as applicable)
  1. Is this claim CONTINUINGTO NEXT MONTH or is it the FINAL CLAIM for this absence? (Please circle as applicable)
  1. If it is the FINAL CLAIM for this absence, on what date did the staff member return to work? ______
  1. For how many WORKING DAYS has the member of staff been absent this month? ______

(Refer to the scheme rules in respect of claiming for absences during school holidays.)

  1. What is your school’s agreed deferred period under the Scheme? ______days.

(This applies only to the first claim for absences arising from illness; there is no deferred period for absences arising from accidents.)

  1. How many days are you claiming for this member of staff’s absence this month? ______
  1. YOU MUST ATTACH MEDICAL CERTIFICATES COVERING THE FULL PERIOD OF ABSENCE.
  1. What is the amount of money you are claiming for this member of staff’s absence this month? (Number of days’ absence multiplied by daily benefit) ______days x ______daily benefit = £ ______

I CERTIFY THAT THIS IS A TRUE AND FAIR CLAIM. TO THE BEST OF MY KNOWLEDGE, NONE OF THE ACCIDENTS IS AS A RESULT OF WAR OR MILITARY SERVICE.

Signed______(Head Teacher) Date ______

Please attach this claim form to the summary sheet, enclose the medical certificates and send to the address below.