Ill Health Retirement Application Form - Pensions

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GUS9 ISLE OF MAN GOVERNMENT UNIFIED SCHEMEDEFERRED ILL HEALTH RETIREMENT APPLICATION FORMB5 – Provide any other information you think is relevant to support your application.If necessary, continue on a separate sheet of paper and staple to this page.B6 Your declaration and consentI declare that I have read and understood the guidance about the Access to Medical Reports Act1988 and that the information I have given on this form is correct and complete to the best ofmy knowledge.Please answer the following questions:1 Do you consent for your OH Adviser to send yourconfidential medical information to the PSPA and then to beforwarded to its Medical Advisers?2 Do you want to see any report from the OccupationalHealth Adviser?Yes Yes No No 3 Do you agree that the PSPA or its Medical Advisers can askany doctor who has been involved in your care for anyinformation relevant to this claim and, if necessary, to sharethat information with an independent examining doctor,and in all cases with any other appointed Medical Advisersfor the purpose of considering your application?4 Do you agree to attend any medical examinations by anindependent doctor if necessary?Yes Yes No No I understand that the letter advising of the outcome of my request to be considered forentitlement to ill health retirement benefits will be sent by the PSPA and myself.Your signature(or someoneauthorised to sign onyour behalf)DateOnce completed, please return your forms to the PSPA Administrators at the address shown on page 1. The PSPA Administrators will thencomplete Part C and forward it on to the Occupational Health Adviser to complete Part D and carry out their assessment and determinationthat the member satisfies the required conditions for a Deferred ill health retirement pension award.10
GUS9 ISLE OF MAN GOVERNMENT UNIFIED SCHEMEDEFERRED ILL HEALTH RETIREMENT APPLICATION FORMPart CTo be completed by the PSPA Pension AdministratorsSurname (CAPITAL lettersplease)Other namesDate of birth D D M M Y Y Y Y VerifiedNational Insurance numberEarnings and Hours as atDate of leaving SchemeDeem DateUp-rated Annual Earnings £ per annumContracted Hours %Part-time Equivalent AnnualEarnings£ per annumCurrent LEL as at claimdateCompleted GUS 9 to be sent to Occupational Health for Assessment:Date Sent …………………………………Signed on behalf of PSPA …………………………..DH Occupational Health DirectorateGaraghyn GlassStrangBraddanDouglasIsle of ManIM4 4RJ11
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Ill Health Retirement Application Form - Pensions

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