Fill and Sign the Illinois Department of Revenue Partnership Replacement Tax Return Due on or Before the 15th Day of the 4th Month Following the Form

Employer’s Liability Accident Report Form Please return this form to:- Please:- Read this form fully before filling it in and where possible answer all questions in CAPITALS. Do not take any action in connection with claims made against you, without our written consent. Forward to us, unanswered, any written communication received. Do not delay the return of this form to us. We will instruct, where necessary, the Solicitor and/or any other Expert necessary for the defence of any claim and also arrange for Witness Statements and/or investigations. The issue of this form does not imply an admission of liability on our part. A Policyholder Details Policy Number Name of Employer Phone No. Mobile No. Email Address Business/Trade or Occupation Are you registered for V.A.T.? Yes No V.A.T. Ref. No. Please note that unless you answer this question we will assume you are registered. State how many employees are in your service. The amount of annual cash wages paid to them. State number boarded and/or lodged. State total value of same. B Injured Employee Name of Injured Person Married/Single Address Age Occupation If the injured person is related to you, please state the relationship, and whether he/she resides with you. Continued overleaf B Injured Employee (continued) State whether the injured person was in your direct employ, or in the service of a Sub-Contractor. (a) Was the injured person’s employment casual or regular? (b) If casual, state how often employed and when last period commenced (c) If regular, how long has he/she been employed by you prior to accident? Is the injured person as insured person under Social Welfare Insurance? If so, state person’s P.R.S.I. Number Please give name and telephone number of person that our claims investigator should make contact with. C Accident Particulars State the date and time of accident. Date Time State the name of place where the accident occurred. State the date on which injured person ceased work State the date on which the accident was reported, and to whom Give a full description of accident Continued overleaf C Accident Particulars (continued) What work was the injured person engaged upon when the accident happened? Was such work part of his/her ordinary duties? Was he/she guilty of any misconduct or disobedience to orders? If there was machinery involved state: (a) On what date injured person commenced working on the machine? (b) For what period was he/she trained, and the name of person who trained him/her? (c) Is there a record of the training provided? (d) Name of person who was supervising his/her work? (e) Were guards provided and were they in position? If not, why not? D Witnesses (a) Give names and addresses of witnesses. (b) Name of Supervisor in charge. (c) Name of Safety Officer. E Details of Injury State fully the nature and extent of injury. Continued overleaf E Details of Injury (continued) Was the injured person taken to hospital? If so, state name of hospital If he/she was detained, please state number of days. Did an ambulance attend the scene? Yes No Give particulars of Hospital or Doctors attending Injured Person Has the Injured person returned to work, and if so, when? If he/she is unable to attend work of any kind, give probable duration of disablement. Has a claim for compensation been made upon you? Is compensation being claimed or received by injured person from any other source? Are you still paying wages? Has the injured person received compensation previously from (a) you? (b) any other employee? State: Number of weeks worked by injured person during the 52 weeks prior to the accident. State number of weeks absent with reason for absences. Statement of wages Set out details of the Injured Person’s wages for the 26 weeks prior to the accident including overtime, etc. Week Ending Basic Wages Overtime Deductions in respect of income Tax and Social Welfare Net Wages 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Total State if any allowance (including Board and/or Lodging) other than cash wages is received by the injured employee: (a) Nature of consideration (b) Cash value F Data Protection Zurich Insurance plc (‘Zurich’) will hold your details in accordance with our Data Protection and Privacy Policy together with all applicable data protection laws and principles. Information you supply may be used by us for the purposes of administering your policy (including underwriting, processing, claims handling and fraud prevention) within the Zurich Financial Services Group and our partners inside and outside the European Economic Area. We may share with our agents and service providers, members of the Zurich Financial Services Group, other insurers and their agents, and with any intermediary acting for you, and with recognised trade, governing and regulatory bodies (of which we are a member or by which we are governed) information we hold about you and your claims history. This includes the Insurance-Link database and the Irish Insurance Federation’s anti-fraud claims matching database. We may also in certain circumstances use private investigators to investigate a claim. We may also need to collect sensitive personal data (for example, information relating to your physical or mental health or the commission or alleged commission of an offence) to assess the terms of insurance we issue/arrange or to administer claims which arise. Unless you have advised us otherwise, we may share information that you provide to companies within the Zurich Financial Services Group and with other companies that we establish commercial links with so we and they may contact you (by email, SMS, telephone or other appropriate means) in order to tell you about carefully selected products, services or offers that we believe will be of interest to you. Please tick here if you do not wish your information to be utilised for these purposes You have a right of access to and a right to rectify data concerning you under the Data Protection Acts 1988 and 2003. Should you wish to exercise this right, please write to the Data Protection Officer, Zurich, Zurich House, Ballsbridge Park, FREEPOST, Dublin 4. To access your data, a fee of €6.35 is chargeable under the terms of the Data Protection Acts and cheque should be made payable to Zurich. By providing us with your information and proceeding with this contract, you consent to all of your information being used, processed, disclosed, transferred and retained for the purposes of insurance administration (including underwriting, processing, claims handling and fraud prevention). Please note that a copy of our full Data Protection and Privacy Policy can be viewed on our website www.zurich.ie or requested by writing to our Data Protection Officer at Zurich, Zurich House, Ballsbridge Park, FREEPOST, Dublin 4. G Declaration N.B. - For your own protection, please note that your Policy provides that the Insured shall not, without the consent in writing of the Company, make any payment, settlement or arrangement, in respect of any claim, nor shall he without their consent, make any admission of liability in respect of any such claim. I\We declare the foregoing particulars to be true to the best of my/our knowledge. I/We hereby authorize the Company and/or any Solicitor(s) instructed by the Company, to deal with all matters arising from the incident at their discrection and, if they deem it expedient, to admit liability and/or negligence on my/our behalf in connection with any claim(s) or legal proceedings. I understand that Zurich may record telephone calls for security & training purposes, for fraud & crime prevention and to ensure the highest level of service. I am aware that I may appoint an Independent Loss Assessor to act on my behalf and help with the preparation of my claim, but the cost of such will be at my own expense. Signature of Insured Please sign and date. X Zurich Insurance plc 0109 Zurich House, Ballsbridge Park, Dublin 4, Ireland. Telephone: 01 667 0666 Fax: 01 667 0644 Website: www.zurich.ie Zurich Insurance plc is regulated by the Financial Regulator. Date