Schools Mutual Insurance Fund Claim Form

Schools Mutual Insurance Fund Claim Form

Please ensure you fill out all applicable fields - also when clicking Submit you receive a "Thank you for your submission message". Failure to receive this message may mean you have not filled out the form in its entirety - meaning we will not receive the form.

You should receive a response notification sent back to the school within 5 working days to confirm receipt of your claim via the Finance Information Communtiy on SecureNet. If you do not receive this notification please contact the Mutual Fund Team or phone 01392 382784. For more information on what happens after you have submit a claim, please read the Mutual Fund FAQ's image - PDF icon (75KB - pdf help).

To be completed within one calendar month of the claim period image - PDF icon (36KB - pdf help).

Need Help? Read the Mutual Fund online claim form instructions.

SECTION 1 - SCHOOL DETAILS
1. School type
2. Teacher or non-teacher claim
3. Type of claim
4. School name
5. School DFE No. (4 digits only)
6. Month of claim
7. Financial year of claim
SECTION 2 - STAFF DETAILS
8. Title
9. Surname
10. Firstname
11a. Nature of absence
11b. If other was selected, please state the nature of the absence
12. Pay Factor Rate
SECTION 3 - CONTINUOUS CLAIM DETAILS
13. First day of sickness (dd/mm/yyyy)
14. Days c/fwd from previous month(s)
15. Date this month - From (dd/mm/yyyy)
16. Date this month - To (dd/mm/yyyy)
17. Pupil days claimed this month
18a. If applicable, please enter the date the school term began for pupils (dd/mm/yyyy)
18b. If applicable, please enter the date the school term ends for pupils (dd/mm/yyyy)
19a. If applicable, please specify Half Term days within this period
19b. If applicable, please specify non pupil days within this period
SECTION 4 - PHASED RETURN TO WORK DETAILS
20. Has the school contacted Wellbeing@Work (or a similar company) and received a referral report?
21. Length of phased return (in weeks)
22. Start date of the phased return (dd/mm/yyyy)
23. End date of the phased return (dd/mm/yyyy)
24. Pupil days claimed during phased return to work (i.e. total number of days not at work during the phased return)
25a. If applicable, please enter the date the school term began for pupils (dd/mm/yyyy)
25b. If applicable, please enter the date the school term ends for pupils (dd/mm/yyyy)
26a. If applicable, please specify Half Term days within this period
26b. If applicable, please specify non pupil days within this period
SECTION 5 - AUTHORISATION
27a. I certify that the above is an accurate record of teacher/non-teacher absence for the period shown. I claim reimbursement in accordance with the SMF scheme. I understand that if an overclaim is made this may be subsequently adjusted.
27b. Certified by (please provide your name)
27c. Date certified (dd/mm/yyyy)

If you need help completing this form please call the Mutual Fund on 01392 382784 or email mutualfund@devon.gov.uk

To be completed within one calendar month before the end of the claim period.