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2. HOME
ADDRESS:
(STREET)
(CITY/DISTRICT/COUNTY)
3. *POSTAL
ADDRESS (if
different from (STREET)
above):
(CITY/DISTRICT/COUNTY)
11. OCCUPATION:
12. EMPLOYER'S
NAME:
13. *EMPLOYER'S
ADDRESS:
(STREET)
(CITY/DISTRICT/COUNTY)
14. NAME OF ACTUAL PLACE OF WORK:
(e.g. School/Department/Division)
(STREET)
(CITY/DISTRICT/COUNTY)
16. ARE YOU CURRENTLY EMPLOYED ELSEWHERE? YES NO
If "YES", state Business Name and Address of other employer.
BUSINESS NAME OF
EMPLOYER:
EMPLOYER'S
ADDRESS:
(STREET)
(CITY/DISTRICT/COUNTY)
*EXAMPLE: Light Pole No. 8 Southern Main Road, Couva OR near BERTIE's Parlour, Industry Lane, Belmont
08/2011
2/NI 15
SECTION "A" - TO BE COMPLETED BY APPLICANT (CONT'D)
17. IS SICKNESS AS A RESULT OF INJURY ON THE JOB? YES NO
FINANCIAL INFORMATION
(If method of payment is "FINANCIAL INSTITUTION", complete below).
The NIBTT considers the foregoing information as instructions from you regarding the deposit of your benefit payment to the
financial institution of your choice.
The NIBTT is not liable for any payment issued to an inaccurate financial institution or account based on these instructions.
NAME OF FINANCIAL
INSTITUTION:
ADDRESS:
(STREET)
(CITY/DISTRICT/COUNTY)
ACCOUNT NUMBER:
Sickness Benefit will be paid for a period of 52 WEEKS, if there is a loss of earnings. At the end of this
period, if the recipient is still ill, he may be eligible for Invalidity Benefit.
DECLARATION
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.
I declare that I am losing earnings and have not worked for the period claimed as a result of my illness.
I hereby give consent for the Medical Certificate at Section "B" to be sent to the National Insurance Board of Trinidad and Tobago.
I hereby give permission for NIBTT to update information from this form.
DATE:
SIGNATURE OR MARK OF CLAIMANT
YYYY MM DD
OCCUPATION: NUMBER:
DATE:
SIGNATURE OF WITNESS TO MARK YYYY MM DD
08/2011
3/NI 15
SECTION "B" - TO BE COMPLETED BY MEDICAL PRACTITIONER
This patient will remain incapable of work for a period of days starting from
(words and figures)
. Confidential information has been sent to the Board's Medical Adviser. YES NO
YYYY MM DD
NAME OF MEDICAL
PRACTITIONER:
SURNAME OTHER NAME(S)
OFFICE ADDRESS:
(STREET)
(CITY/DISTRICT/COUNTY)
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.
MEDICAL
PRACTITIONER'S
STAMP
DATE:
SIGNATURE OF MEDICAL PRACTITIONER
YYYY MM DD
NOTE: In the case of a FIRST or SECOND CERTIFICATE the period of certified incapacity must not exceed 14 DAYS including Sundays and
Public Holidays.
In the case of a THIRD OR SUBSEQUENT CERTIFICATE THE PERIOD entered must not exceed 28 DAYS including Sundays and Public
Holidays.
08/2011
4/NI 15
SECTION "C" - TO BE COMPLETED BY EMPLOYER
INSTRUCTIONS FOR COMPLETION
(i) This Section must be completed by the Employer before the Application is submitted to the Board.
(ii) In completing Column 5 (c) and 6 (d) below calculate weekly earnings as follows:
(a) Earnings mean wages or salary and include overtime payments, long service payments, commissions, payment for standby duty, all
allowances, etc.
(b) Weekly Earnings = Monthly Earnings x 3 (e.g. $ 800 x 3 = $ 184.62 ) OR;
13 13
YYYY MM DD
5. 6.
WEEKLY RATE OF PAY DAILY EARNINGS DURING SICKNESS
State Weekly Rates of Pay for the 13 week (a) (b) (c) (d)
period BEFORE the week in which the employee's PERIOD OF ABSENCE TOTAL DAILY
NO. EARNINGS
incapacity started. 5(b) Mondays only. NO. OF DURING
(a) (b) (c) FROM TO DAYS SICKNESS
WK DATE ACTUAL WEEKLY YYYY MM DD YYYY MM DD $ c
NO. EARNINGS
YYYY MM DD $ c 1
1 2
2 3
4
3
5
4
5
7. Was Loss of Earnings CAUSED BY SICKNESS?
6
(a) YES (b) NO
7
If "NO", Please state reason for Loss of Earnings
8
10
11
12
13
08/2011
5/NI 15
EMPLOYER'S DECLARATION
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.
NAME:
SURNAME OTHER NAME(S)
POSITION:
COMPANY
STAMP
(If any) DATE:
SIGNATURE OF EMPLOYER YYYY MM DD
NAME:
1. NAME, N.I. NO. AND DATE OF BIRTH CONFIRMED ON I.A. SYSTEM? YES NO
SERVICE CENTRE
RECEIVED
STAMP
DATE:
SIGNATURE OF CUSTOMER SERVICE REPRESENTATIVE
YYYY MM DD
08/2011
6/NI 15
SECTION "D" - FOR OFFICIAL USE (CONT'D)
DATE:
SIGNATURE OF SUPERVISOR/CLERICAL OFFICER II YYYY MM DD
YES NO
2. WAS THE APPLICANT IN INSURABLE EMPLOYMENT WHEN INCAPACITY COMMENCED?
YES NO
3. WAS LOSS OF EARNINGS SUFFERED?
4. IS THE "10 IN 13" TEST SATISFIED? (See Section "C", Question 5 on page 4) YES NO
TOTAL
08/2011
7/NI 15
SECTION "D" - FOR OFFICIAL USE (CONT'D)
PART "III" - DETERMINATION OF APPLICATION (CONT'D)
8. (a) WEEKLY RATE OF BENEFIT IN CLASS = $ (See Section "D", Part III Question 7(c)).
YYYY MM DD YYYY MM DD
DATE:
SIGNATURE OF PROCESSING OFFICER YYYY MM DD
10. DECISION/AUTHORISATION:
(a) SICKNESS BENEFIT ALLOWED AND AUTHORISED, FOR THE PERIOD AND RATE, AT 8(c) ABOVE.
(b) SICKNESS BENEFIT DISALLOWED ON THE GROUNDS AT 9 ABOVE.
(c) APPLICANT NOTIFIED OF DECISION ON FORM NI 44/ NI 53; DATE:
YYYY MM DD
(d) DECISION RECORDED ON I.A. SYSTEM: DATE:
YYYY MM DD
DATE:
SIGNATURE OF MANAGER/SUPERVISOR/C.O. II
YYYY MM DD
08/2011