» Blank ESA 113 Form. Example Only.

Your Full Name

Please Enter Today's Date

Who is your manager, employer or HR manager?

Have you previously made a flexible working requests? Describe below

EXAMPLE 1: I have not made any previous flexible working requests. EXAMPLE 2: I have previously made a flexible working request on 1st January.

What is your working pattern and role?

Example: My current working pattern and role is 5 days a week as an office admin assistant.

Give details of the change you would like to make to your working pattern.

EXAMPLE: I would like to reduce my work hours from 35 to 30 per week.

When would you like this change to come into effect?

How can you employer deal with any effects the change could have?

EXAMPLE 1: I suggest sharing my job with another employee. EXAMPLE 2: I suggest that I could be being available to answer calls in emergencies.

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Your Full Name

Please Enter Today's Date

Who is your manager, employer or HR manager?

Give details of how your health impacts work. Or how your work impacts your health. You do not need to disclose your mental health problem if you do not want to.

Example: I've been diagnosed with anxiety and I'm receiving treatment for my mental health condition. I'm finding it difficult to concentrate at the moment and I'm concerned that without changes to my work I might have an accident.

What is your working pattern and role?

Example: My current working pattern and role is 5 days a week as an office admin assistant.

Provide details of the reasonable adjustments you would find helpful and why.

EXAMPLE: a later start time so that I can miss the rush hour because I'm finding it difficult to be around lots of people

How would this adjustment benefit your employer?

EXAMPLE: This would meant that I can arrive calm and clear headed ready for work.

Please suggest how you and your employer could deal with any effects of the changes.

EXAMPLE: I would like to suggest working later into the evening to make up for the time lost .

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Today's Date

Address Of The Person You Are Sending A Letter To

Street Address Address Line 2 City ZIP / Postal Code Country

Please Enter Their Phone Number

Name The Person You Are Caring For

What Date Did You Begin Careing For This Person

What Is Your Relationship To This Person?

List Their Conditions Or Disabilities

What Are The Main Areas Where They Need Care

Describe The Main Difficulties You Have

What Is Your Name.

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Your Full Name

Please Enter Today's Date

N.I Number

Please Enter The Date Which You Sent Off Your Application To The DWP.

Who Are You Sending The Letter To?

Please Enter The Address Of The Person / Organisation

Please Detail The Medial Evidence That You Are Including

Covering Letter For GP in Seeking Home Assessment ESA or PIP.

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DLA Template Diary

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Migraine Reasonable Adjustments Request Template

Your Full Name

Please Enter Today's Date

Who is your employer?

Employer's Address

Who are you sending the letter to?

How many days off have you taken?

Please describe the symptoms of you condition.

What adjustments would you like to be considered?

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Repaying Debt To Your Energy Supplier

Please Enter Today's Date

Your Full Name

Your Address

Please Enter Your Email Address

Telephone

Who Is Your Energy Supplier?

Please Enter Your Account Number With The Supplier

Type of supply:

How Much Do You Owe Your Supplier? (£)

How Much Do You Currently Pay Back Per Week? (£)

Per Week, How Much Would You Like To Pay Back? (£)

Please Provide The Supplier Some Information About Your Situation. Please see example.

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Challenging Your PIP Decision

Your Full Name

Please Enter Today's Date

Please Enter The Date Which You Submitted Your Claim.

Date Of Birth

Your Address

Insert The Name Of Your Healthcare Professional

Address Of The Recipient

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Healthcare Professional Information Request

Your Full Name

Please Enter Today's Date

N.I Number

Date Of Birth

Your Address

Insert The Name Of Your Healthcare Professional

Address Of The Recipient

Please Select Your Claim Type

Why Are You Making This Claim?

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Blank ESA 113 Form. Example Only.

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