Insurance : Ex Gratia Payments - Home Page

Insurance : Ex Gratia Payments______________________________________________________________________________PLEASE ATTACH THE FOLLOWING DOCUMENTS11. A letter from your Insurance Company rejecting your claim for this loss.Please note that your application cannot be processed unless this isproduced.12. A signed statement by an independent witness to the incident.13. Original purchase receipt for the items involved.14. I certify that the information given above is correct and I apply for considerationfor an ex-gratia payment................................................................................................Signature of Applicant.......................................................................................................................... DateCOUNCIL USE ONLY15. Approved by the Head of the Establishment where loss occurred.Signature .............................................................................................................Printed Name.......................................................................................................Designation..........................................................................................................Establishment ......................................................................................................Date .....................................................................................................................16. Authorisation of Payment by Head of ServiceSignature .............................................................................................................Printed Name.......................................................................................................Date .....................................................................................................................Note: Any payment will require to be met from the Service budget.When all the form has been completed, it should be submitted to the RiskManagement Section, Finance Service, Fife House (01), North Street, Glenrothes,Fife, KY7 5LTCurrent version at June 2012 Page 6 of 6