Form

Employment and Support Allowance claim form

Use this form to claim Employment and Support Allowance (ESA) if you're eligible. You may be able to apply for Universal Credit.

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

This file may not be suitable for users of assistive technology. Request an accessible format.

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.

ESA renewal claim form: Only complete this form if you got ESA in the last 12 weeks: fill in on screen

This file may not be suitable for users of assistive technology. Request an accessible format.

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.

ESA renewal claim form: Only complete this form if you got ESA in the last 12 weeks: print

This file may not be suitable for users of assistive technology. Request an accessible format.

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.

Welsh: Ffurflen hawlio adnewyddu Lwfans Cyflogaeth a Chymorth: Dylech dim ond llenwi’r ffurflen hon os cawsoch Lwfans Cyflogaeth a Chymorth yn ystod y 12 wythnos diwethaf: llenwch ar y sgrin

This file may not be suitable for users of assistive technology. Request an accessible format.

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.

Welsh: Ffurflen hawlio adnewyddu Lwfans Cyflogaeth a Chymorth: Dylech dim ond llenwi’r ffurflen hon os cawsoch Lwfans Cyflogaeth a Chymorth yn ystod y 12 wythnos diwethaf: argraffu

This file may not be suitable for users of assistive technology. Request an accessible format.

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

You may not have to fill in this form. The quickest way to apply for ESA is by phone.

You may be able to apply for Universal Credit. Check you’re eligible for ESA before you apply.

Where to send your form

Send the completed form to your Jobcentre Plus office.

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.