Form

Employment and Support Allowance (ESA) claim form

Use this form to apply for income-based and contribution-based ESA, if you're eligible. You may need to apply for Universal Credit or 'new style' ESA instead.

Documents

ESA claim form you can print and fill in with a pen

Welsh: Ffurflen hawlio Lwfans Cyflogaeth a Chymorth y gallwch ei hargraffu a'i llenwi gyda beiro

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If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email accessible.formats@dwp.gsi.gov.uk. Please tell us what format you need. It will help us if you say what assistive technology you use.

Details

Check you’re eligible for ESA before you apply. You may need to apply for Universal Credit or ‘new style’ ESA instead.

There’s a different form to apply for ‘new style’ ESA.

You can also call the contact centre to apply for income-based and contribution-based ESA.

Contact Jobcentre Plus if you need this claim form in Braille, large print or audio.

Where to send your form

Send or take your completed form to your local Jobcentre Plus.

Published 1 April 2013
Last updated 30 November 2018 + show all updates
  1. Revised ESA1 interactive and print versions (English and Welsh). Corrected a web page URL in the notes.
  2. Added ESA1RR forms - English and Welsh - renewal reclaim versions only to be complete if you got Employment and Support Allowance in the last 12 weeks. Revised ESA1 forms - print and interactive - English and Welsh.
  3. Revised notes for ESA1 interactive form. New contact details for online helpdesk.
  4. Published revised ESA claim form you can print and fill in with a pen – English and Welsh.
  5. Published revised ESA claim form you can download, fill in on screen, save – and then print.
  6. Expanded notes section to inlcude advice for claimants who have claimed ESA before.
  7. Added updated versions - Oct 2013.
  8. First published.