Ill Health Retirement Application Form - Pensions

GUS9 ISLE OF MAN GOVERNMENT UNIFIED SCHEMEDEFERRED ILL HEALTH RETIREMENT APPLICATION FORMSection 2 – Ill Health Retirement Assessment FormPart ATo be completed by Deferred Member or Existing Deferred MemberPlease provide following detailsTitle (Mr, Mrs, Miss, Ms, Dr) Sex: Male FemaleSurname (CAPITAL lettersplease)Other namesDate of birth D D M M Y Y Y Y VerifiedNational Insurance numberLatest or current Job titleand GradeLatest or current Annual Fulltime Salary£Latest Weekly ContractualHoursPlease provide full details of your sickness absence over the last 5 years.If there has been no sickness absence, please write ‘NONE’.Dates Nature of illness where known Tick one boxFromToFullpayHalfpayNopaySSPIf necessary, continue on a separate sheet of paper and staple to this page.4