Form NI 15
Sickness Benefit Application
View Instructions
Clear Form
1.Name
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. Birth Certificate PIN Number
7. Was evidence of Date of Birth Previously Submitted?
Yes
No
8. Gender
Male
Female
9. Marital Status
-- select an option --
Single
Married
Divorced
Widowed
10. Telephone Number
Home
Phone
Office
Phone
Cell
Phone
11. Occupation
12. Employer's Name
13. Employer's Address
Street Address
City / District / County
14. Name of Actual Place of Work
15. Address of Actual Place of Work
Street Address
City / District / County
16. Are you currently employed elsewhere?
Yes
No
17. Is sickness as a result of injury on the job?
Yes
No
18. Last Date Worked
19. Date Loss of Earnings started
20. 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
Submit and Print