Claims for Disablement

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Please note the portal is currently offline due to a problem with the internet provider

NATIONAL INSURANCE FORMS

Claim for Disablement

National Insurance Number*
National Registration Number*
Name
First Middle Last
Address
District
Parish
Zip/Postal Code
Date of Birth
Date Format: DD slash MM slash YYYY
Tel. No.
Cell No.
Email
Marital Status
- Single
- Married
- Divorced
- Widowed
DETAILS OF ACCIDENT
What is the date and time of the accident/incident or the development of the prescribed disease in respect of which you are claiming Disablement Benefit?
Date Format: DD slash MM slash YYYY
Time

: HH

MM
Where did the accident/incident occur? (Please provide specific place of accident/incident)
What injury did you suffer?
State in what way you are disabled as a result of the accident/incident?
Are you fit to travel if you are required to a medical examination?
- Yes
- No
I agree to the extent of my disablement being determined by a:
- Single medical practitioner
- Medical Panel
Have you attended a hospital for treatment of the injury/disease?
- Yes
- No
Name of Hospital State whether in-patient or out-patient Name of ward if in-patient Hospital reference of admission no. Date (from and to)
Were X-rays taken?
- Yes
- No
Do you agree to your records being obtained by the Director of National Insurance for the assistance of the Medical Board or Medical Tribunal in their consideration and assessment of your claim?
- Yes
- No
ALTERNATE PAYEE DETAILS
To be completed if payment is to be made to someone on your behalf
National Insurance Number
National Registration Number
Name
First Middle Last
Address
District
Parish
Zip/Postal Code
Tel No.
Cell No.
Email
BANKING DETAILS
To be completed where payment of this claim is to be deposited to a bank account.
I hereby authorise payment in respect of this benefit to be lodged to the bank account given below.
Name(s) of account
Account Number
Name and Location of Branch
Please provide proof of bank account - The header of a bank statement of a stamp from your bank verifying your account details.
Upload proof of bank account here.
DECLARATION
I hereby declare that the information given on this form is true to the best of my knowledge and belief.
Signature*
Date*
Date Format: MM slash DD slash YYYY
If you are unable to sign this application, it may be signed of your behalf by someone who should state that they have done so.
WARNING - Any person who makes a false statement or any false representation for the purpose of obtaining benefit, commits a crime punishable by a fine or a term of imprisonment or both.

Please note the portal will be offline for maintenance from Friday, November 27th until Monday, November 30th

Please note the portal is currently offline due to a problem with the internet provider

NATIONAL INSURANCE FORMS

DETAILS OF ACCIDENT

ALTERNATE PAYEE DETAILS

BANKING DETAILS

DECLARATION

Employees

Unemployed

Employers

Self- employed

Pensioner

Contribution

Employees

Unemployed

Employers

Self-Employed

Pensioners

National Insurance Scheme Copyright © 2020.

Name of Hospital	State whether in-patient or out-patient	Name of ward if in-patient	Hospital reference of admission no.	Date (from and to)