THE DAVE LAWRENCE WAKEFIELD SCHEME  

CLAIM FORM 

            Fill in this form only if you are making a claim. Then send it to the address below, 

            Accompanied by your sick note, death certificate. 

            NAME_________________________________________________                         

            ADDRESS______________________________________________                         

            ______________________________________________________                          

            TEL No:________________________________________________                         

            Date of Accident/Illness/Death_____________________________                  

            Next of kin                                                                                                          

            Contact number                                                                                                   

            Brief Details______________________________________________                       

            _______________________________________________________                                    

            ______________________________________________________                          

            _______________________________________________________                                    

            Treated by_______________________________________________                        

                                                (GP or Hospital) 

            Sick note obtained*   YES/NO 

            *If yes! For how long?_________________ 

            Signed__________________________ Date________________ 

            Wakefield DIA membership number                                                   

            Send this form as soon as possible to:  SCHEME MANAGER 

                                                                          ROY MITCHELL  

                                                                                  I PERTH DRIVE 

                                                                            WEST ARDSLEY 

                                                                               WAKEFIELD  

                                                                                 WF3 1TZ                                                                                                                         TEL 01132528621 

            ** Reminder ** you can only make a claim if your illness or injury prevents you from working. You will not be paid during the first two weeks following your accident or the start of your illness.                                                                                                                                                                                          JUNE 09