City & General Direct (UK) Ltd. 1 Stonegate Road, Leeds, LS6 4HZ Tel: 0113 216 1144 Fax: 0113 274 5886 E-mail: info@cgduk.com

Broker name/if applicable
E-Mail address
Name of school
Post code
Policy number
Teacher	Non teacher
Name of Absentee
1st day absence
Added coments