.

This form will only if:

• your computer,
• open Reader

The form will not in:

• versions of Acrobat Reader
• other readers, for example Preview on a Mac or Foxit on a PC

If you are having technical difficulties:

• downloading the form
• avigating around the form, or
• printing the form

Please contact the helpdesk.

Phone:
Email:

Opening hours
Monday to Friday: am - pm
Closed on all Public and Bank Holidays.

For help and advice on the information you need to put on the form or
about the benefit you want to claim, contact the office that deals with the
benefit.
New style
Employment and
Support Allowance

Before you start

This is a claim form for new style Employment and Support Allowance
(new style ESA).

Notes for you to keep

Please make sure you read these notes before you fill in your claim form.
They tell you the steps you will need to take to claim new style ESA. They
also contain useful information to help you understand what happens
during your claim, and telephone numbers that you may need to use in
the future.

How to claim new style ESA

Step 1 - Book a New Claim Appointment
To make your claim you need to take your completed form to a New
Claim Appointment at your local jobcentre. They will check your claim
form and look at the supporting information you have provided. They
will also talk to you about what help they can give you while you claim
new style ESA. Your appointment may last up to 1 hour and 20 minutes.
If you do not have details of an appointment yet, you should contact us
to arrange one.
If you are already getting Universal Credit you may not need to make
an appointment. Use your online Universal Credit account to contact us
for more information on what to do with this claim form and if you need to
make an appointment.
• If you got this claim form online: book a New Claim Appointment
straight away by calling: 0800 328 5644 or Textphone: 0800 328 1344.
• If you have already called us to get this claim form sent to you:
someone will get in touch with you through your preferred method of
contact (for example, phone, letter or email) to tell you about your New
Claim Appointment. You do not need to call us. If you have not heard
about your New Claim Appointment within 1 week of your initial phone
call, please get in touch with us on the telephone number above.
• If you collected this claim form from your local jobcentre: you should
have already had your New Claim Appointment booked for you when you
collected your form. You do not need to call us.
NSESAF1 0 /19

NSESAF1 1 of 22
Your claim will not be looked at until you have been to your
appointment.
If you are unable to attend a New Claim Appointment at your local
jobcentre due to your illness, disability, injury or health condition let us
know. We may be able to offer you further help and support.
Calls to 0800 numbers are free from landlines and mobiles.

Step 2 - Complete the form

Please make sure you complete all parts of the form before attending your
New Claim Appointment. You may not be able to get new style ESA if you
do not answer all the questions on the form that apply to you. If you need
to provide more information you can do this in Part 10: More information.
If you need help completing the form, you can ask a friend, relative or an
organisation that you know and trust to help you. You can also get help by
contacting Jobcentre Plus.
If you are filling in this form on behalf of someone else, please make sure
you also complete Part 11 of the claim form.
If you need this form in Braille, large print or audio, please call us on: 0800
328 5644 or Textphone: 0800 328 1344

Step 3 - Declaration
Read, sign and date the Part 12: Declaration.
If you got this claim form online make sure you print your completed claim
form before your appointment.
Remember, you will need to bring all parts of the claim form with you to
your New Claim Appointment, along with your supporting information we
have asked you to provide. You can find a list of what else you will need to
bring with you to your appointment in the ‘What happens next’ section of
this claim form.

More information about new style ESA

What is new style ESA?
If you have an illness, disability, injury or health condition, new style ESA
offers you:
• financial support if you are unable to work
• personalised help to help you get into work when you’re able to, or make
steps towards going back to work

Who can get new style ESA?

You can get new style ESA if your health affects your ability to work and
you’ve paid enough National Insurance contributions in the last 2 to 3
years. To check your National Insurance record or read about National
Insurance credits and contributions, visit the HM Revenue & Customs
(HMRC) website at www.gov.uk/check-national-insurance

2 of 22 NSESAF1
You may get new style ESA if you’ve lived or worked abroad and paid
enough UK National Insurance or the equivalent in a European Economic
Area (EEA) country, or a country with which the UK has an agreement.
Any earnings you get from employment, pensions or other benefits might
affect how much new style ESA you’re paid.
Other household income or savings will not affect your payment.

Supporting information you will need to provide

If you’re getting Statutory Sick Pay, please bring your current Statement
of Fitness for Work with your claim form to your New Claim Appointment.
Statements of Fitness for Work are also known as fit notes, medical
certificates, doctor’s statements, or sick notes. If you can’t get Statutory
Sick Pay, you do not normally need to get a Statement of Fitness for work
for the first 7 days of your illness, disability, injury or health condition. We
will need to see either a letter from your doctor or an original Statement
of Fitness for Work from the eighth day you want to claim new style ESA
for. There is more information about what information you need to bring
to your New Claim Appointment in the ‘what happens next’ section at the
end of the claim form.

Work Capability Assessments

As part of your claim to new style ESA, following your New Claim
Appointment, you will be asked to take part in a Work Capability
Assessment. This will help us understand your current illness, disability,
injury or health condition.
We will ask you to read, fill in and return a Capability for Work
questionnaire about how your illness, disability, injury or health condition
affects your ability to work. You may then be asked to go to a face-to-face
assessment with a healthcare professional.
Please note: the face-to-face assessment is not a medical examination.
It is to help us understand how your illness, disability, injury or health
condition affects your ability to work.
This means we can give you the right support to help you work when
we can. This could include work you haven’t thought about before. Not
everyone is asked to go, but if you are given an appointment, it’s important
you attend. If you do not fill in and send back the questionnaire, or go
to your Work Capability Assessment if you are asked to, you could lose
your new style ESA payments.
We understand you might be nervous about your assessment. If you would
like someone to go with you to the assessment, please take them with
you. The person you take should know and understand you and your needs
(for example, a relative, support worker, or friend. They must be 16 or over).
You can find out more about the Work Capability Assessment and see
a video of a face-to-face assessment by visiting the Health Assessment
Advisory Service website at www.chdauk.co.uk

NSESAF1 3 of 22
After your assessment, we’ll decide how much your illness, disability, injury
or health condition limits your ability to work. We will make our decision
using:
• the report written by our healthcare professional
• the answers from your questionnaire and,
• any other medical evidence we get from your General Practitioner (GP) or
healthcare professional who knows about your illness, disability, injury or
health condition.
If we find you capable of work, we will stop paying you new style ESA.
If we find that your illness, disability, injury or health condition limits your
ability to work, you will be placed into one of two different groups. These
are called the work-related activity group and the Support Group.
We will pay you a new style ESA assessment rate until you’ve had your
Work Capability Assessment. The amount of benefit we pay you once
you’ve had your Work Capability Assessment could change depending on
which group you are placed in.
If you’re placed in the Work-Related Activity Group or Support Group we
will backdate any arrears to week 14 of your claim.

Work-Related Activity Group

If you show you’re able to start doing things to prepare for work in the
future, you will be put into the work-related activity group. If you are
placed in the work-related activity group, new style ESA can only be paid
for a maximum of 365 days.

Support Group
If your illness, disability, injury or health condition severely limits your
ability to work, you will be put into the support group. There is no time limit
on how long you can claim new style ESA if you’re in the support group.

Waiting days
Normally, you will not get any new style ESA for the first 7 days from when
you want to claim. These are called waiting days. Not everyone has to
serve waiting days. For example, claimants who have been on new style
ESA at any time in the previous 12 weeks.

New style ESA and Universal Credit

Check if you’re eligible for Universal Credit. If you are, you could get
Universal Credit at the same time as new style ESA. To find out more visit
www.gov.uk/Universal-credit
If you get both Universal Credit and new style ESA at the same time,
your new style ESA payment will be deducted from your Universal Credit
payment - you are not guaranteed to get any extra money.

4 of 22 NSESAF1
Part 1: Start your claim
What date do you want to 13/03/2020 / /
claim new style ESA from?
You will need to provide medical evidence, for example, a
Statement of Fitness for Work, to support your claim.

Part 2: About you

Surname Shaw

First name and any other Eleanor Rose

names
Any other surnames you have
been known by

Title Miss

Date of birth 18/10/1993

Letters Numbers Letter

National Insurance (NI) J X 7 6 0 5 1 0 C
number
You can get this from payslips or from tax papers.
Or get in touch with Jobcentre Plus.

Address 23 Camberwell Grove

Postcode SE5 8JA

Are you happy for us to write to No

you at this address?
Yes

If not, what is the address

where you would like us to write
to you?

Postcode

Email address, if you agree we

can contact you by email

Mobile phone number 07545223580

Are you happy for us to send No

you text messages about your
claim? Yes

Daytime phone number if

different, including area code

NSESAF1 5 of 22
Part 2: About you continued
Are you expecting a baby? No
Yes What date is the
baby due?

Part 3: About your illness, disability, injury or health condition

What date did your illness, 16/03/2020
disability, injury or health
condition start?

Please give the name of your COVID-19

illness, disability, injury or
health condition as noted on
your medical certificate
Otherwise known as Statement
for Fitness for Work
Dr Thurston and Partners
Name of your doctor or
medical practice

Address of the doctor who Camberwell Green Surgery

17 Camberwell Green
signs your medical statements
Otherwise known as Statement
of Fitness for Work

Postcode SE5 7AF

Phone number of the doctor 020 7703 3788

who signs your medical
statements including area code

Have you been in hospital as an No

in-patient in the last 52 weeks?
Yes Please tell us about this below

Name of hospital

Address of hospital

Postcode

Date you went into hospital

Have you come out of hospital? No

Yes Date you came out of hospital

6 of 22 NSESAF1
Part 4: Special Rules
Please read this note before answering the next two questions
We have ‘special rules’ for people who are terminally ill. This means people who are not
expected to live longer than another six months.
If you qualify for special rules, then you will get a faster decision and the higher rate of new style
ESA from the date your claim was made. Please ask us if you need help with applying under
special rules.

Do you think special rules No Go to Part 5: About work

apply to you?
Yes

Have you already asked for, or No Ask your doctor or specialist for a DS1500 Report.
do you have a DS1500 Report
The DS1500 Report is a report about your medical
for a claim for Disability Living
condition. You will not have to pay for it.
Allowance (DLA), Personal
Independence Payment (PIP) or You can ask the doctor’s receptionist, or nurse, or a
Universal Credit (UC)? social worker to arrange this for you. You do not have to
see the doctor. You should be given the DS1500 Report
straight away. Ask for the report in a sealed envelope if
you do not want anyone to see it.
If there is a delay in getting your DS1500 Report, still
come to your New Claims appointment to prevent a
delay in your claim being processed. Then send us your
DS1500 Report as soon as you can. You will be told
where to send this to at your appointment.

Yes You do not need to get another DS1500 Report. We

will get a copy of your DS1500 Report from these other
benefits.

NSESAF1 7 of 22
Part 5: About work
We need to know about any work you are doing now. We consider you to be working if you are
still employed or self-employed but are unable to work at the moment because of an illness,
disability, injury or health condition.
Please tell us about any work that is:
• employed or self-employed
• full-time or part-time
• permanent or casual
• paid or unpaid
• work as a company director
• time spent on work-based training

Are you working at the No Go to Part 6: About statutory payments

moment?
Yes Answer the following questions.
Still tick Yes and answer the
questions below if you are If you have more than one employer, please tell us
employed or self-employed but about them in Part 10: More information. You will need
unable to work at the moment to answer all of the questions below for each additional
because of an illness, disability, employer you have.
injury or health condition; if you
are getting Statutory Sick pay, or
if you do voluntary work.

If you usually work, but are not 16/03/2020

working at the moment because
of your illness, disability, injury or
health condition, please tell us
the date you last worked?
If you worked a night shift,
please tell us the date your shift
ended.

How many hours a week do you 18 hours

usually work?

How much do you usually get £ 175

paid?
How often are you paid this Every week
amount?
Every month
Every 4 weeks
Every year
Other, please specify

8 of 22 NSESAF1
Part 5: About work continued
Employer’s name Corporation of London

Employer’s address Barbican Centre, Silk Street

Postcode EC2Y 8DS

Employer’s phone number 020 7638 4141

Your job title Retail Assistant

Will your employer keep paying No

you if you are off work because
of an illness, disability, injury or Yes
health condition?

Is the work you do voluntary? No

Yes

Are you self-employed or a No

sub-contractor?
Yes

NSESAF1 9 of 22
Part 6: About statutory payments
Please read this not before answering the next few questions.
We need to know about any statutory payments you are getting from your employer, or have
claimed in the past. We will tell you if they affect your claim for new style ESA.
For example, you must tell us about:
• Statutory Adoption Pay
• Statutory Maternity Pay
• Statutory Paternity Pay
• Statutory Sick Pay
• Shared Parental Pay
These types of payments are required by law. They are paid by an employer to an employee if the
employee satisfies the qualifying conditions.

Are you currently getting any No

statutory payments?
Yes Answer the following questions.
If you need to tell us about any other statutory
payments, tell us in Part 10: More information. You
will need to answer all of the questions below for each
additional statutory payment you get.
If you are getting Statutory Sick Pay, please bring
your SSP1 form with you to your New Claims
Appointment.

Name of statutory payment

Who do you get your statutory

payment from?
How much money do you get, £
and how often?
Every week
Every month
Every 4 weeks
Every year
Other, please specify

What day is it paid?

Have you ever had a statutory No

payment in the past?
Yes If yes, tell us about this statutory payment below

Name of statutory payment

Who did you get your statutory

payment from?

10 of 22 NSESAF1
Part 6: About statutory payments continued
How much money did you get, £
and how often?
Every week
Every month
Every 4 weeks
Every year
Other, please specify

Date of the last payment or the

date you stopped being entitled
to get the statutory payment

Part 7: About pensions

Are you currently getting any No Go to Part 8: About permanent health insurance
pensions?
Yes Please tell us about them below.
By ‘pension’ we mean:
• an occupational pension If you have more than one pension, please tell us about
• a personal pension them in Part 10: More information. You will need to
• a retirement annuity contract answer all the questions below for each additional
• a payment from the Armed pension you get.
Forces Compensation Scheme
Tick Yes if you get:
• regular pension payments
• an annual compensation
payment from a previous job
• lump sum payments from
an occupational or personal
pension, these could be paid
yearly
• payments from the Pension
Protection Fund
• Financial Assistance Scheme
payments

What type of pension are you Personal pension

getting?
Occupational, work or employee’s pension
Retirement annuity contract
Public service pension
Pension paid to you as a beneficiary

NSESAF1 11 of 22
Part 7: About pensions continued
Name of your pension or annuity
provider

Address of your pension or

annuity provider

Postcode

Phone number of your pension

or annuity provider, including
area code

How much is the pension before £

any deductions? For example,
deductions like income tax. Every week
And how often is it paid?
Every month
Every 4 weeks
Every year
Other, please specify

How much is the pension after £

any deductions?
Every week
Every month
Every 4 weeks
Every year
Other, please specify

How much are the deductions £ for

and what are they for?
£ for

£ for

When did the pension start

12 of 22 NSESAF1
Part 7: About pensions continued
Did you choose to take regular No Go to Part 8: About permanent health insurance
income from the pensions
scheme instead of buying an Yes
annuity?
Was this the maximum income No
you could take?
Yes

Did you inherit your pension? No

Yes

NSESAF1 13 of 22
Part 8: About permanent health insurance
Do you currently get any No Go to Part 9: How we pay you
permanent health insurance
payments? Yes Please tell us about them below.
If you have more than one permanent health insurance
payment, please tell us about them in Part 10: More
information. You will need to answer all the questions
below for each additional permanent health insurance
payment you get.

Name of the employer or

company paying the permanent
health insurance premiums
Address of the employer or
company paying the permanent
health insurance premiums

Postcode

Phone number of the employer

or company paying the
permanent health insurance
premiums, including area code

Has your contract of No

employment ended with this
employer? Yes When did it end?

Have you contributed more than No

half of the premiums towards
any permanent health insurance Yes
payment?

14 of 22 NSESAF1
Part 9: How we pay you
Please tell us your bank or building society account details below.
It is very important you fill in all the boxes correctly, including the building society roll or
reference number, if you have one. If you tell us the wrong account details your payment may
be delayed or you may lose money.
You can find the account details on your chequebook, bank card or bank statements. If you do not
know the account details, ask the bank or building society.
• you can use an account in your name, or a joint account
• you can use someone else’s account if:
- The terms and conditions of their account allow this, and
- They agree to let you use their account, and
- You are sure they will use your money in the way you tell them
• you can use a credit union account. You must tell us the credit union’s account details. Your
credit union will be able to help you with this.
• if you are an appointee or a legal representative acting on behalf of the claimant, the account
should be in your name only

We pay money directly into your bank account.

Many banks and building societies will let you collect your money at the Post Office.
We will tell you when we make the first payment and how much it will be for. We will tell you
if the amount we pay into the account is going to change.
Finding out how much we have paid into the account.
You can check your payments on account statements. The statements may show your
National Insurance (NI) number next to any payments we have made. If you think a payment
is wrong, get in touch with the office that pays you straight away.

Name of the account holder Eleanor Rose Shaw

Please write the name of the
account holder exactly as it is
shown on the chequebook or
statement

Full name of the bank or Monzo Bank Ltd

building society

Sort code 0 4 0 0 0 4
Please tell us all 6 numbers, for
example: 12-23-56

Account number 8 8 3 8 6 9 8 4
Most account numbers are 8
numbers long

Building society roll or

reference number
If you are using a building society account, you may need
to tell us a roll or reference number. This may be made up
of letters and numbers, and may be up to 18 characters
long. If you are not sure if the account has a roll or
reference number, ask the building society.

NSESAF1 15 of 22
Part 10: More information
If you:
• have more than one employer
• get more than one statutory payment
• have more than one pension
• get more than one permanent health insurance payment
then you can tell us about them here. If there is not enough space, please use a separate
sheet of paper. Make sure that you:
• write your full name and National Insurance number on each sheet of paper
• sign and date each sheet that you use
Do not tell us about your disability, illness or health condition here. We will send you a
questionnaire about this later.

I am self-employed as an actress. All future job opportunities and castings have been paused indefinitely because of
COVID-19 so I will not be making any substantial income as an actress.

Between acting jobs - 'resting' jobs as they are known in the business - I work as a retail assistant on a zero-hours
contract and as front-of-house staff at a yoga studio on a freelance basis. At the yoga studio it is effectively a
zero-hours contract but we operate on a freelance basis where I invoice for my hours worked and am expected to
work out and pay my own taxes out of my income there.

As of Monday 16th March, the Barbican Centre closed indefinitely and my role is not one that can be performed at
home so I have no anticipated income from there.

All my shifts at the yoga studio have been cancelled for the foreseeable future.

I do not believe I am entitled to SSP from either job as a casual worker.

16 of 22 NSESAF1
Part 11: Filling in this form for someone else
Are you filling in this form for No Go to Part 12: Declaration
someone else?
Yes Please tell us about yourself below.

Surname

Other names

Any other surnames you have

been known by

Title Please choose

Date of birth

Letters Numbers Letter

National Insurance (NI) number

Address, including postcode

Postcode

Mobile phone number

Daytime phone number,

if different
Are you signing this form for No Go to Part 12: Declaration
someone else?
Yes Even though you can fill in this form for another adult,
they must still sign it themselves unless one or more of
the following reasons shown on the next page.

NSESAF1 17 of 22
Part 11: Filling in this form for someone else continued
I am signing this form for I have Power of Attorney for them
someone else because Remember to sign the Declaration in Part 12
I am a receiver or deputy for them under a Court of
Protection Order, or in Scotland a tutor, curator or
guardian appointed in terms of the law.
Remember to sign the Declaration in Part 12
The Department for Work and Pensions has already
appointed me to get their benefits and to deal with letters
about their benefits.
We will send all letters about this claim directly to you.
They cannot manage their own affairs because of a
disability, illness or health condition.
We will get in touch with you about this. The Department for
Work and Pensions may appoint you to get their benefits and
to deal with letters about their benefits.
They cannot sign for themselves because of their
disability, illness or health condition.
We will get in touch with you about this.

If the person does not know you

are signing this form for them,
please tell us why.

18 of 22 NSESAF1
Part 12: Declaration
By submitting this claim you agree that the information you’ve given is complete and correct.
While you’re receiving new style Employment and Support Allowance, you’ll report changes to
your circumstances straight away.
If you give wrong or incomplete information, or you do not report changes, you may:
• be prosecuted
• need to pay a financial penalty
• have your new style Employment and Support Allowance reduced or stopped
• be paid too much new style Employment and Support Allowance and have to pay the
money back
If we pay you less than we should, we may pay you the money that we owe you.

I agree that:
• the Department for Work and Pensions
• any approved health care professional advising the Department
• any organisation with which DWP has a contract for the provision of assessment services may ask
any of the people or organisations mentioned on this form for any information which is needed to
deal with:
- this claim for benefit
- any request for this claim to be looked at again and that the information may be given to that
approved health care professional or organisation to the Department.
I agree to my doctor, or any doctor treating me, being informed about the Secretary of State’s
determination on:
• limited capability for work
• limited capability for work related activity, or
• both
This is my claim to new style Employment and Support Allowance

Signature Date
18/03/2020

Please tick this box if someone

filled in this claim form for you.

Our service standards

At Jobcentre Plus we aim to provide a high standard of customer service at all times.
Details of the standard service you can expect from us can be found at www.gov.uk
You can access our website from many libraries. For more information, please contact
Jobcentre Plus.

Equality and diversity

We are committed to treating people fairly, regardless of their disability, ethnicity, gender,
sexual orientation, transgender status, marital or civil partnership status, age, religion or
beliefs. Please contact us if you have any concerns.

NSESAF1 19 of 22
How we collect and use information
When we collect information about you we may use it for any of our purposes. These include:
• social security benefits and allowances
• child maintenance
• employment and training
• investigating and prosecuting tax credits offences
• private pensions policy and
• retirement planning
We may get information about you from other parties for any of our purposes as the law allows to
check the information you provide and improve our services. We may give information about you to
other organisations as the law allows, for example to protect against crime.
To find out more about our purposes, how we use personal information for those purposes and
your information rights, including how to request a copy of your information, please see
www.gov.uk/dwp/personal-information-charter

What happens next

If you need to book a New Claim Appointment, do this straight away to continue your claim to
new style ESA. Information about if you have to do this and how to do it can be found at the start
of this claim form.
You will need to provide the following at your New Claim Appointment:
• this claim form
• your medical statements (otherwise known as a Statement of Fitness for Work or ‘fit note’)
• it is important that you provide proof of your identity at your appointment. Please look at
page 21 ‘Confirming your identity’ for a full list of what you should provide
You should also provide (if applicable):
• DS1500 Report
• SSP1 form
• proof of any pensions
• proof of payments from a permanent health insurance policy
We will not be able to deal with your claim or there may be a delay in processing your claim if:
• you have not answered all the questions on this form that apply to you
• you do not arrange a New Claim Appointment with your work coach if you need to
• you do not bring the information we have asked for to your New Claim Appointment
After your New Claim Appointment, we will write and tell you when the Work Capability
questionnaire is being sent to you. This questionnaire will be about your disability, illness or health
condition. Please look out for this in the post.
If we can pay you new style ESA we will write to you to tell you how your benefit has been worked
out and how you will be paid. We will pay you into the account you have told us about.
If we cannot pay you new style ESA we will write to you to tell you why and what to do if you
disagree with the decision.

20 of 22 NSESAF1
Confirming your identity
It is important that we can be sure of your identity when you claim new style ESA. We will need to
see official documents that help prove your identity. A National Insurance number is not proof of
identity.
Please take a look at the list below to see what you will need to provide at your New Claim
appointment. You will need to have:
• one document from the List 1,
• and two documents from List 2.

List 1, provide one of the following current documents:

UK passport
EEA passport
UK photo driving licence (both
parts)
If you do not have any of the
above, you can provide
National identity card
Residence permit or card
Immigration status document
Registration or naturalisation
certificate

List 2, provide two of the following original documents:

Birth certificate
Recent bank or building society
statement
Council tax statement
NHS medical card
If you do not have any of the
above, you can provide
Debit or charge card
Expired passport
Expired full or provisional UK
driving licence
Local authority rent card
Marriage or civil partnership
certificate
Registration or naturalisation
certificate
Tenancy agreement

NSESAF1 21 of 22
Official use only
Has the claimant ID been verified? No Yes

Has the Claimant Commitment been No Yes

accepted?
Is this a dual or new style only claim? Dual New style only

Do special rules apply? No Yes

Interviewing officers signature

Date

22 of 22 NSESAF1