COIDA Claim Form

{{company_name}}

{{company_address}}

Phone: {{phone}} | Email: {{email}} | Web: {{website}}

COIDA Claim Form

Complete all sections of this coida claim form in BLOCK CAPITALS. Incomplete forms cannot be processed.

Employee Details

Request / Information

Declaration

I confirm that the information provided in this form is true, complete, and accurate to the best of my knowledge. I understand that providing false information may result in disciplinary action.

Manager Review

HR Action

Acknowledgement & Signatures

By signing below, both parties confirm they have read, understood, and agreed to the terms of this document.

Parties

This Agreement is entered into on {{date}} between {{company_name}} (the "Company"), having its registered office at {{company_address}}, and {{employee_name}} ({{employee_id}}) (the "Employee"), collectively referred to as the "Parties".

Recitals

1. WHEREAS the Company wishes to formalize the arrangements set out below;
2. WHEREAS the Employee agrees to be bound by the terms of this Agreement;
3. NOW THEREFORE, in consideration of the mutual promises herein, the Parties agree as follows:

Definitions

• "Company" means {{company_name}} and its affiliates and successors.
• "Employee" means the individual identified above and their authorized representatives.
• "Effective Date" means the date this Agreement is signed by both Parties.
• "Confidential Information" means non-public business, technical, or personal information disclosed under this Agreement.

Obligations of the Parties

1. The Employee shall perform their duties in good faith and in compliance with applicable law and Company policy.
2. The Company shall fulfil its obligations toward the Employee in accordance with this Agreement and the underlying employment contract.
3. Each Party shall promptly notify the other of any circumstance materially affecting performance under this Agreement.

Indemnification

Each Party agrees to indemnify and hold harmless the other from and against any claims, damages, liabilities, costs, and expenses (including reasonable legal fees) arising out of any breach of this Agreement or any negligent or wrongful act or omission of the indemnifying Party, subject to applicable law and the limits of liability set out herein.

Term & Termination

1. This Agreement takes effect on the Effective Date and continues until terminated in accordance with its terms.
2. Either Party may terminate this Agreement with written notice in accordance with the underlying employment contract.
3. Provisions relating to confidentiality, indemnification, and governing law survive termination.

Governing Law & Dispute Resolution

This Agreement is governed by the laws of the jurisdiction in which {{company_name}} is registered. The Parties shall attempt to resolve disputes through good-faith negotiation, and failing resolution, through the competent courts of that jurisdiction.

Acknowledgement

Document Control