Form NI 15A

Continuation Claim to Sickness Benefit

Name

First Name

Middle Names (if any)

Surname

hereby consent to the follow-up Medical Certificate at Section “B” being submitted to the National Insurance Board.

National Insurance Number

I declare that to the best of my knowledge and belief the information given by me is true and correct and I am aware that if there is any statement in this declaration which is false in fact or which I know or believe to be false or do not believe to be true, I am liable on summary conviction to a fine of three thousand dollars ($3,000.00) and to imprisonment for two years in accordance with Sect 33, NI Act Chap 32:01.

Particulars of Witness to Mark (Where Claimant cannot sign)

Is the Claimant able to sign?

Yes

Witness Name

First Name

Middle Names (if any)

Surname

Address

Street Address

City / District / County

Occupation

Identification

Electoral Identification Card

Passport

Driver's Permit