Employer Needs Assessment Form

Employers details

please describe

Client name: *

Principal office address: *



Website address:

Nature of client's business: *

Locations

Other sites	Location	Nature of business

Main point of contact

Name: *

Job title: *

Address: *



Telephone: *

Email:

Number of employees

	Male	Female

Office based:

Manufacturing:

Night workers:

Home workers:

Workers requiring licenses:

Workers based on external sites:

Lone workers:

TOTAL:

Company sick pay policy (please describe)

Notes

Gallagher Benefits Consulting Limited is authorised and regulated by the Financial Services Authority.
Registered Office: 9 Alie Street, London, E1 8DE. Registered No. 0772217 England & Wales. www.gallaghereb.com
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