Form NI 119
Disablement Benefit Claim
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Clear Form
Section A - To be completed by the Applicant
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. Occupation
9. Date of Accident
10. Time of Accident
11. Place of Accident
Street Address
City / District / County
12. Last Date Worked
13. Employer's Name at time of Accident
14. Employer's Telephone Number
Phone
15 .Employer's Address of actual place of work
(e.g. School/Department/Division)
Street Address
City / District / County
16. Exact place/location where accident occurred
Street Address
City / District / County
17. Have you ever applied for injury Benefit as a result of the same Accident/Prescribed Disease
Yes
No
26. Please indicate the method of payment of benefit
Mail to my Postal Address
Deposit to Financial Institution
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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