Section I - Confirmation of Unemployment Certificate Please complete ALL of this form PART I - CLAIMANTS DETAILS First name(s) Last name Date of Birth Daytime telephone number Your address PART 2 - JOB SEEKERS AGREEMENT Do you have a Job Seekers Agreement with the Department for Work and Pensions? Please enclose a copy of the Job Seekers Allowance Decision Letter. Please note that we will not be be able to consider your without this document unless you are exempt. No Please give details why PART 3 -JOB SEARCH INFORMATION If no please specify why on opposite page Since becoming unemployed, have you been continuously available for work AND actively seeking employment of at least 16 hours per week. Yes No Are you registered with any job clubs / employment agencies? Yes No If yes please provide details overleaf Are you attending any training or educational courses? Yes No If yes please provide details on a separate sheet IMPORTANT: For each month that you have been unemployed you must provide evidence of 3 positions you have applied for AND please attach copies of application and response letters to support the details. PART 4 - CURRENT STATUS Have you completed any work either paid or unpaid since you became unemployed? Yes No If yes please provide details overleaf Do you currently have any job offers? Yes No If yes please provide details overleaf Have you started, or are to start, a new job? Yes No If yes please enter start date Please enclose a copy of the job offer letter and your P45 from the Department for Work and Pensions PART 4 - CURRENT STATUS I declare that the answers I have provided on this certificate are true and complete to the best of my knowledge and honest belief. I confirm that I have disclosed to you any work I have undertaken, either paid or unpaid, since the commencement of this or any other current claim. I am aware that if I knowingly give incorrect information I will lose all rights under the policy, I will have to repay any benefit I have received and legal action could be held against me. I authorise the Department of Work and Pensions (DWP), Her Majesty's Revenue and Customs (HMRC), Recruitment Agencies and any other relevant parties to release, on request by Paymentshield Limited and , information that is relevant to my claim.
Section I - Confirmation of Unemployment Certificate Please complete ALL of this form PART I - CLAIMANTS DETAILS First name(s) Last name Date of Birth Daytime telephone number Your address PART 2 - JOB SEEKERS AGREEMENT Do you have a Job Seekers Agreement with the Department for Work and Pensions? Please enclose a copy of the Job Seekers Allowance Decision Letter. Please note that we will not be be able to consider your without this document unless you are exempt. No Please give details why PART 3 -JOB SEARCH INFORMATION Since becoming unemployed, have you been continuously available for work AND actively seeking employment of at least 16 hours per week. If no please specify why on opposite page Yes No Are you registered with any job clubs / employment agencies? If yes please provide details overleaf Yes No Are you attending any training or educational courses? Yes No If yes please provide details on a separate sheet IMPORTANT: For each month that you have been unemployed you must provide evidence of 3 positions you have applied for AND please attach copies of application and response letters to support the details. PART 4 - CURRENT STATUS Have you completed any work either paid or unpaid since you became unemployed? If yes please provide details overleaf Yes No Do you currently have any job offers? Yes No If yes please provide details overleaf Have you started, or are to start, a new job? Yes No If yes please enter start date Please enclose a copy of the job offer letter and your P45 from the Department for Work and Pensions PART 4 - CURRENT STATUS I declare that the answers I have provided on this certificate are true and complete to the best of my knowledge and honest belief. I confirm that I have disclosed to you any work I have undertaken, either paid or unpaid, since the commencement of this or any other current claim. I am aware that if I knowingly give incorrect information I will lose all rights under the policy, I will have to repay any benefit I have received and legal action could be held against me. I authorise the Department of Work and Pensions (DWP), Her Majesty's Revenue and Customs (HMRC), Recruitment Agencies and any other relevant parties to release, on request by Paymentshield Limited and , information that is relevant to my claim.
Covea-Claim-Form-Emp-Unemp-Income-Protection.docx