NI51
Survivor's Benefit Application
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1
Section A
Particulars of the Deceased
2
Section B
Particulars of Applicant
3
Section C
Particulars of Widows/Widowers
4
Section D
Particulars of Child/Children
5
Section E
Particulars of Witness to Mark
1
Section A
Particulars of the Deceased
2
Section B
Particulars of Applicant
3
Section C
Particulars of Widows/Widowers
4
Section D
Particulars of Child/Children
5
Section E
Particulars of Witness to Mark
Particulars of Deceased Insured Person
1. Name of Deceased
First Name
Middle Names (if any)
Surname
2. Address
Street Address
City / District / County
3. National Insurance Number
4. Date of Birth
5. Date of Death
6. Gender
Male
Female
7. Employment Record from 1972, April 10.
Name of Employer
Address of Employer
Registration No.
Period of Employment
Add Employment Record
8. Name of Last Employer
9. Address of Last Employer
Street Address
City / District / County
10. Last Date Worked
11. Was deceased in receipt of an Invalidity Pension?
Yes
No
12. Was deceased in receipt of a Retirement Pension?
Yes
No
13. Did the deceased work or live in Canada or worked in any of the CARICOM countries?
Yes
No
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Particulars of Applicant
1. Name of Applicant
First Name
Middle Names (if any)
Surname
2. 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 Numbers
Home
Phone
Office/Work
Phone
Cell
Phone
8. Marital Status
-- select an option --
Single
Married
Divorced
Widowed
9. Valid Indentification
Electoral Identification Card
Passport
Driver's Permit
10. Relationship to Deceased Insured Person
11. Please indicate the benefit(s) for which you are applying
Widow's Benefit
Widower's Benefit
Child Allowance
Orphan Allowance
Dependent Parent's Pension
12. Was an application submitted for a Funeral Grant?
Yes
No
13. Have you applied for or are receiving a Survivor's benefit?
Yes
No
14. Please indicate the method of payment for benefit
Mail to my Postal Address
Deposit to Financial Institution
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Particulars of Widows/Widowers
The National Insurance Act provides for the payment of benefit to Common-Law Spouses of Deceased Insured Persons.
1. Are you the lawful spouse of the deceased?
Yes
No
2. If you were not married to the deceased insured kindly complete
(a) Is there a known surviving spouse of the deceased?
Yes
No
(b) Have you been nominated as Spouse by the deceased person?
Yes
No
(c) How long have you lived together in the common-law union?
(d) Were the both of you living together up to the time of his death?
Yes
No
(e) Have you been nominated as Spouse by another person?
Yes
No
3. Were you pregnant at the date of your spouse's death?
Yes
No
4. Were you mentally or physically disabled at the date of your spouse's death?
Yes
No
5. Were you wholly or mainly maintained by the deceased?
Yes
No
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Particulars of Child/Orphan
The term “Child” means an unmarried child, who is unemployed and under the age of nineteen.
1. Is/Are child/children/orphan(s) in respect of whom allowance is claimed?
(a) Child/Children/Orphan(s) of the deceased?
Yes
No
(b) Step Child/Children of the deceased?
Yes
No
(c) Maintained by you?
Yes
No
(d) Living in your home?
Yes
No
2. Please indicate below, the particulars of the child/children.
A letter from the school must be submitted for children over age 16 where the date of death of the Insured is prior to 2004/03/01
Where the child is disabled, attach
Form NI 34A
to support this.
Name of Child/Orphan
Relationship to Deceased
Date of Birth
Employed
Married
Disabled
Add Child Record
3. Letter from place of learning attached where the date of death is prior to 2004/03/01
Yes
No
For persons claiming Dependent Parent benefit ONLY
1.Were you wholly or mainly maintained by the deceased?
Yes
No
2. Is the other parent alive?
Yes
No
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Particulars of Witness to Mark
Is the Claimant able to sign?
Yes
No
Witness Name
First Name
Surname
Address
Street Address
City / District / County
Occupation
Identification
Electoral Identification Card
Passport
Driver's Permit
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