11.07.2015 Views

Insurance : Ex Gratia Payments - Home Page

Insurance : Ex Gratia Payments - Home Page

Insurance : Ex Gratia Payments - Home Page

SHOW MORE
SHOW LESS

Create successful ePaper yourself

Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.

<strong>Insurance</strong> : <strong>Ex</strong> <strong>Gratia</strong> <strong>Payments</strong>______________________________________________________________________________FIFE COUNCILAPPLICATION FOR CONSIDERATION FOR AN EX-GRATIA PAYMENTAPPLICANT’S DETAILS1. Applicant’s Name (Mr/Mrs/Miss/Ms) ....................................................................2. Applicant’s Address .............................................................................................………………………………………………………………..………………………………………………………………..3. Applicant’s Telephone No ....................................................................................4. If Council employee, which Service employed by ................................................INCIDENT INFORMATION5. When did the Accident happen? ..........................................................................6. <strong>Ex</strong>act place of incident.....................................................................................................................................................................................................................7. Please give details of incident giving rise to this application..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................__________________________________________________________________FURTHER INFORMATION8. Original cost of item lost or damaged £................................................................9. Date of Purchase .................................................................................................10. Amount applied for £............................................................................................Current version at June 2012 <strong>Page</strong> 5 of 6

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!