Form NI 38
Invalidity Benefit Application
View Instructions
Clear Form
(1) This application must be submitted within three (3) months of the first day of being certified an invalid.
(2) Birth Certificate and Affidavit (if necessary) must be submitted with claim 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. Gender
Male
Female
7. Telephone Number
Home
Phone
Cell
Phone
8. Marital Status
-- select an option --
Single
Married
Divorced
Widowed
9. Maiden Name (where applicable)
10. Last Occupation
11. Name of Last Employer
12. Last Employer's Registration Number (If known)
13. Employment Record from 10 APRIL, 1972
Employer
Address of Employer
Type of Employment
Period of Employment
Add Employment History
14. Did you work or live in Canada or worked in any of the CARICOM countries?
Yes
No
15. Last Date of Employment
16. Have you ever applied for an Invalidity Benefit?
Yes
No
17. Are you able to travel to a Medical Centre for medical re-examination?
Yes
No
18. Is invalidity the result of an injury on the job?
Yes
No
19. 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