NI114
Employment Injury Benefit Application for Medical Expenses
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1
Section A
Personal Information
2
Section B
Details of Claim
1
Section A
Personal Information
2
Section B
Details of Claim
Personal Information
1. Name of Applicant
First Name
Middle Names (if any)
Surname
2. Home Address
Street Address
City / District / County
3. Postal Address
My Postal Address is different from my Home Address
4.National Insurance Number
5. Date of Birth
6. Gender
Female
Male
7. Telephone Numbers
Home
Phone
Office/Work
Phone
Cell
Phone
8. Employer's Name
9. Employer's Address
Street Address
City / District / County
10. Employer's Registration Number
11. Date of Accident/Development of Industrial Disease
12. Time of Accident
13. Period for which Medical Expenses are claimed
Period Start Date
Period End Date
14. Did you meet the total costs of Medical Expenses
Yes
No
15. Please indicate the method of payment of benefit
Mail to my Postal Address
Deposit to Financial Institution
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Details of Claim
(a) Medical Practitioner's Visits
Medical Practitioner
Office Address of Medical Practitioner
Date Visited
Time Visited
Fees Paid
TOTAL
0
Add Visits
(b) Hospitalisation
Hospital/Nursing Home
Address
Period of Stay
Items Claimed
Amount Paid
TOTAL
0
Add Hospital
(c) Surgery/Operations
Medical Practitioner
Date of Surgery
Type of Surgery
Amount Paid
TOTAL
0
Add Surgery/Operations
(d) Drugs, Dressings, X-Rays
Pharmacy/Supplier
Address of Pharmacy
Referred by
Date Prescription Filled
Amount Paid
TOTAL
0
Add Prescription
(e) Paramedical Treatment/Equipment/Appliance
Paramedic/Supplier
Address of Paramedic/Supplier
Referred by
Type of Appliance/Equipment Fitted/Treatment Recieved
Amount Paid
TOTAL
0
Add Treatment
(f) Constant Attendance and Care
Name of Attendant
Address
No. Of Days Attended
Amount Paid
TOTAL
0
Add Attendee
(g) Travelling Expense
Date of Travel
Points of Travel
Mode of Transport
Amount Paid
TOTAL
0
Add Travel Expense
(h) Magnetic Resonance Imaging (MRI)
Name of Institution
Address of Institution
Referred by
Date of Visit
Amount Paid
TOTAL
0
Add MRI
Particulars of Witness to Mark
(Where Claimant cannot sign)
Is the Claimant able to sign?
Yes
No
Witness Name
First Name
Middle Names (if any)
Surname
Address
Street Address
City / District / County
Occupation
Identification
Electoral Identification Card
Passport
Driver's Permit
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