Use this form to ask for a backdated benefits payment.
This form should take no longer than 10 minutes to complete.
To complete this form you will need:
- your name
- your email address
- your phone number
- your address
- the reason for your claim
- the date you want to claim from
This form expires after 20 minutes of inactivity.
We are a data controller for the purposes of data protection legislation.
We hold and process all personal information in line with data protection legislation.
You can find out how we manage and process your data in our privacy policy.
