NI19
Employment Injury Benefit Application
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Clear Form
1
Section A
Applicant Information
2
Section B
Particulars of Accident
3
Section C
Particulars of Witness to Mark
1
Section A
Applicant Information
2
Section B
Particulars of Accident
3
Section C
Particulars of Witness to Mark
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. Marital Status
-- select an option --
Single
Married
Divorced
Widowed
9. Occupation
10. Employer's Name
11. Employer's Address
Street Address
City / District / County
12. Name of Actual Place of Work
13. Address of Actual Place of Work
Street Address
City / District / County
14. Are you currently employed elsewhere?
Yes
No
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15. Date of Accident
Time of Accident
16. Last Date Worked
17. Date Resumed Work
18. Exact place/location where accident occured
19. Did accident occur while travelling in employer's transport?
Yes
No
20. State clear details of the cause of the accident
21. State details of injury sustained
22. Give name and address of any witness to the accident
First Name
Middle Names (if any)
Surname
Street Address
City / District / County
23. Was accident reported to your Employer?
Yes
No
24. Date of First Visit to Medical Practitioner
25. Name of Medical Practitioner
First Name
Middle Names (if any)
Surname
26. Address of Medical Practitioner
Street Address
City / District / County
27. Did you meet the cost of medical expenses?
Yes
No
28. Relapse: Is this application in support of a Relapse?
Yes
No
29. Please indicate the method of payment of benefit
Mail to my Postal Address
Deposit to Financial Institution
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Particulars of Witness to Mark
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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