Form NI 19A
Continuation Claim to Injury Benefit
View Instructions
Clear Form
SECTION “A” - To be completed by Applicant
Name of Applicant
First Name
Middle Names (if any)
Surname
National Insurance Number
Name of Employer
Particulars of Witness to Mark
(Where Claimant cannot sign)
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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