Injury Benefit Application Form - IoMG Unified Scheme

Public Sector Pensions AuthorityInterim Injury Benefit Scheme 2012Application for Injury BenefitsImportant: Please complete this form in CAPITAL LETTERS and in BLACK INKSection ASection BTo be completed by the Employing DepartmentTo be completed by the ApplicantGuidance to all contributors of this applicationThis form must be completed for all injury benefits applications.Before completing this form please read carefully the separate guidance provided for each contributor to this application.Please note that injury benefits may not be due if the accident or illness was wholly or mainly due to or seriously aggravated by yourown culpable negligence or misconduct.ATo be completed by the Employing DepartmentPart 1 – Complete for all applications1. Title (tick) Mr: Mrs: Miss: Ms: Dr:2. Surname3. Other Names4. Maiden Name (if applicable)5. NI Number6. Date of Birth/ /7. Payroll Reference8. Is the applicant Pensionable? Yes: What is the Ref No?No: Do they have a private pension plan? No: Yes:Don’t Know:9. If the applicant was in the Unified Scheme,has an application for a pension on ill-health grounds been accepted? No: Yes:10. What has happened as a result of a work related injury or disease?Sick leave commenced on/ /Don’t Know:Employment ended onLower paid employment began onThe employee died on/ // // /Injury App 05/2012 Public Sector Pensions Authority

Part 2 – Complete this part if employment ended, on sick leave or if there has been a change to lower paidemployment1. What was the applicant’s job?2. Where did they work?3. Was this employment part time? No: Give the hours worked per week:Yes:Standard Whole-Time Hours for job:Tick here if hours varied:4. Give details of all known periods of employment.Continue on a separate piece of paper if you do not have enough room here.Employer From To

Part 2 continued5. Please provide details of all sick leave and reasons relating to this application.Dates Reason Tick as appropriatePlease provide information about the nature ofFrom To Full Pay Half Pay Nil Payillness as fully as possible

Part 2 continued6. Pay Details(a) Annual Rate of pay on If lower paid employment has started, use pay on£last day of employmentlast day of original employment(b) Total Pensionable Pay £/ / to(TPP) for last 3 years£/ / to/ // /£/ /to/ /(c)Notional Whole-TimeEquivalent (part timers only)£If employment has ended and the officer was on unpaid sick leave at the end of their employment pleaseshow below details of any paid leave or paid notice granted after the unpaid sick leave.Paid Leave: from / / to / /Paid Notice: from / / to / /Payment in lieu of notice: from / / to / /TPP is 365 days to include paid employment, paid sick leave (including SSP), annual leave and paidnotice, but excludes unpaid sick leave, temporary injury allowances, strike days and payment in lieu of notice.7. If claiming for permanent benefit, has the claimant been inreceipt of Temporary Injury Allowance? No: Yes:8. Complete this part only if the applicant has changed to lower paid employment(a)What is the applicant’s job after the change to lower paid employment?(b)Where do they work? (eg Name of Department, unit etc)(c) Rate of pay in new job? £per annum(d) Rate of pay before change? £per annum(e) Is the pay protected? No: Yes: for how long(f) Is this employment part time? No: Yes: hours worked per weekTick here if hours vary

Part 2 continued9. Has the employee claimed compensation (damages) from the employer? No: Yes:If yes please complete the boxes belowThe Employing Department Solicitors/Insurers detailsFull Name:Address:Telephone Number:Reference Number:Part 3 – Complete this part only if the employee has died as a result of an injury or disease1. Employee’s date of Death:/ /2. Did the deceased leave a spouse/civil partner? No: go to item 6.Yes:give details below.3. Spouse/Civil Partner’s first names:4. Date of Birth:5. Date of Marriage/Civil Partnership:/ // /6. Did the deceased leave any financially dependent relatives? No:Yes:please complete the box belowName Relationship to deceased Date of Birth/ // // // // // // /

Part 4 - Complete in all casesa) Death cases only:Is the employee’s date of death at Part 3.1 verified by sight of the No: Yes:death certificate?Have details of the marriage/civil partnership at Part 3.5 been verified No: Yes:by sight of the marriage/civil partnership certificate?Have details of the spouse/civil partner’s name and date of birth at No: Yes:Part 3.3 & 3.4 been verified by sight of the birth certificate?Have details of any dependent relatives, including children, given at No: Yes:Part 3.6 been verified by sight of the birth certificate?b) All cases: Please send the following documents with this form Please TickAccident ReportsJob DescriptionReports by Occupational Health DoctorsCopies of any internal investigation reports connected with this claimEmployer Statementc)All cases In the Employing Authority’s opinion was the injury or disease wholly or No: Yes:mainly due to or seriously aggravated by the claimant’s own culpablenegligence or misconduct?Declaration: I certify that the details given in Section A Parts 1 – 4 are correct to the best of my knowledge and beliefSignature:Please Print Name:Status:Telephone Number:Email Address:Date:/ /Employing Authority Official Stamp:

BTo be completed by the ApplicantPart 51. Please confirm that you have checked the information in Section A No: Yes:and any enclosures provided by your employerIs there anything that you disagree with? No: Yes:If YES please tell us on a separate sheet what you disagree with and why.Do not amend Section A.2. Are you claiming, or are you awaiting the outcome of a claim, for any of the following DSC benefits since thestart of your injury/disease etc?Please tick the relevant box(es) Incapacity Benefit Industrial Injuries Disablement BenefitYou must inform us in the box below of any other benefits or pensions you are receiving or if you are appealingagainst any DSC decisions.Please tell us below the address and telephone numbers of the DSC Offices that are dealing with your benefits.The Incapacity Benefit Office is:The Industrial Injuries Office is:3. Do you have any educational, professional or technical qualifications? No: Yes:If YES please give full details.Subject Qualification (GCSE/GCE/Diploma/Degree etc) Grade

Part 5 continued4. Are you working at present? No: Yes: If YES please answer the following questionsAre you claiming Job Seekers Allowance? No: Yes:What job are you doing?What are your duties?What are your gross earnings (before Tax, National Insurance, etc)?£How many hours a week do you work?5. Have you made, or do you intend to make, a claim No: Go to item 6for damages against your employer, or a third partybecause of your injury/disease? Yes: Complete the boxes belowThe full name of my solicitor is:Their Address is:Their telephone Number is:Their Reference Number is:Has the claim been settled? No: Yes:I understand that:If I have received any damages or compensation in respect of the matters giving rise to my claim forInjury Benefits that the amount of benefit I may be entitled to may be reduced; andIf I receive any damages or compensation after I have been awarded an Injury Benefit that I will haveto repay some or all of that benefit.6. Has a claim been made under the Criminal Injuries No: Yes:Compensation Scheme because of your injury/disease?

Part 5 continuedTO BE SIGNED IN ALL CASESDamages or CompensationYou must carefully read the accompanying guidance in the attached ‘Injury Benefits - Notes for Guidance’before signing this declaration.I declare that I have read the ‘Notes for Guidance’ and understand the following:I cannot receive all of my damages or compensation recovered from any source (such as Criminal Injuries CompensationScheme) for the same injury and all of my Injury Benefits. If I am entitled to Injury Benefits, the PSPA will offset from myInjury Benefits any (meaning ‘all’) damages or compensation recovered for the same injury as I am claiming for here.Only where a loss of earnings element is clearly identifiable and delineated in the settlement the PSPA may, in certaincircumstances, limit the amount to be offset to that amount.This means that:If I have already recovered damages or compensation before making this claim I must tell the PSPA on this claim form sothat my Injury Benefits can be adjusted (reduced) from the outset to take into account the damages or compensation. Iam aware that depending on the amounts involved, this could result in me not being entitled to any Injury Benefitspayments.If I recover damages or compensation in respect of the same injury as I am claiming here after I have made this claim butbefore any payment is made, I must tell the PSPA immediately so that my Injury Benefits can be adjusted (reduced) fromthe outset to take into account the damages or compensation. I am aware that depending on the amounts involved, thiscould result in me not being entitled to any Injury Benefits payments.If I have made a claim for damages or compensation but it has not been settled by the time my Injury Benefits can bepaid, PSPA will pay me any award I am entitled to on account and on the clear understanding that I must notify them ofthe details within 14 days of the settlement and that, depending on the amounts involved, when the offset is calculated Iwill have to repay some or all of the Injury Benefits I have been paid and my allowance will be either reduced or stopped.Signature:Date:7. Are you a member of a Personal No: Yes:or Private pension scheme?Policy Reference Number:Name and Address of Scheme:

Part 5 continuedAbout your injury or illness.8. Please tell us what injury or disease, which has arisen out of your work, you are claiming for.Include any diagnosis or description of your condition that you can.Please continue on a separate sheet if you need more space.

Part 5 continued9. Please provide details of the incident or events giving rise to your injury or disease.Please continue on a separate sheet if you need more space.

Part 5 continued11. Declaration and signature of ClaimantPlease read and sign below. Without this signed declaration your application will not be considered.I declare that:to the best of my knowledge and belief the information I have given on this form is correct andcomplete.I am applying for Injury benefits due to an injury/disease which I consider to be wholly or mainlyattributable to my employment and is not due to or seriously aggravated by my own culpable negligenceor misconduct.I understand that:I have read and understood the Injury Benefits Guide and that completion of this application form enables me tobe considered for an injury benefit award.If I have received any damages or compensation in respect of my claim for Injury Benefit, any injury benefit thatI may be entitled to may be reduced, and I may have to pay some back.I understand that the PSPA will contact the DSC to seek their confirmation of the amount of any DSC benefits Imay be entitled and the amounts in payment.If I have received certain DSC benefits or pension benefits, any injury benefit that I am entitled to may bereduced and I may have to pay some back.I understand that the Scheme Medical Adviser will contact me separately and I may be asked to attend amedical review and/or provide my consent for the release of my medical details for the schemes medicaladvisers.I agree that any medical information necessary to decide my case will be obtained by me at my expense frommy General Practitioner/Consultant, and or other sources. I give consent for the PSPA or their Medical Advisersto approach my Occupational Health Department or any other relevant sources for information if required.Signature:Date:Please return completed form and documents to the PSPA, Injury Benefits, Goldie House, 1-4 Goldie Terrace, Douglas,ISLE OF MAN. IM1 1EB.

Part 6We need your consent to access information about your claimTo be completed by the applicant.Please read the following guidance about release of medical information beforecompleting this section, then sign and date the declaration and consent on the nextpage. Failure to provide information will result in your application being delayed orrejected.The PSPA may need additional reports from *your doctor, so that it can consider your application for Injury Benefits.(*This means any doctor who has treated you, or cared for you, or who has been involved in diagnosing your condition,and includes an Occupational Health Doctor). The PSPA may also need you to be examined by their independentmedical adviser.Access to Medical Reports Act 1988The Medical reports your doctor prepares for the PSPA or its medical advisers are subject to the ‘Access to MedicalReports Act 1988’. Under that Act you can either:• allow your doctor to send it straight to the PSPA without you seeing it first, or• ask to see the report before they send it to the PSPA, or• you can instruct the doctor not to send the report to the PSPA at all.Reports written by a doctor who has not been involved in your treatment, care or diagnosis or medical records thatalready exist are NOT subject to the Access to Medical Reports Act 1988.If you decide that a report requested by PSPA or it’s medical advisers can come straight to us without you seeing it first,you can still ask to see it at any time up to 6 months after we receive it.The 'Consent' you sign at the end of this section will tell your doctor whether you wish to see any report they preparebefore they send it to PSPA. If you decide you want to see the report before your doctor sends it, you have 21 days fromwhen the PSPA asks for the report to let your doctor know that you wish to see it. You can view the report for free, butyour doctor is entitled to charge you a reasonable fee if you want a copy for yourself. Your doctor can withhold all or partof the report from you. But, if they do so for professional medical reasons, they must tell you that they are doing so.If you think that the report your doctor has prepared is misleading or incorrect in any way, you can ask them in writing toamend it. Your doctor can refuse to amend the report, but if they do they will invite you to send a letter with yourcomments that they can attach to the report, before they send it to the PSPA.Release of medical information and examination by an independent doctorIn order to clarify or confirm certain aspects of your medical condition the PSPA may sometimes need to ask for othermedical, or relevant information (e.g. from your GP, Specialist or employer). We may also need you to be examined byits’ independent medical adviser. So that they understand what benefit you are claiming for we might need to pass any orall of the reports and medical or relevant information to them. The PSPA will also need to pass all the information itgathers to its Medical Advisers.If you do not agree to the release of reports or other information about your medical condition, the PSPA may be unableto consider your application for benefits.

Part 6 continuedYour consent under the Access to Medical Reports Act 1988I declare that I have read and understood the guidance about the Access to Medical Reports Act 1988.Please tick one of the following choices.I do not want to see any report from my doctor(s) before it is sent to the PSPA.I want to see any report from my doctor(s) before it is sent to the PSPA.Your consent for release of informationPlease tick one of the following choices.“I agree that for the purpose of considering my application, the PSPA and or their medical advisers canobtain information from my employer, DSC or any doctor or specialist who has been involved in my carethat is relevant to this claim, that the documents which were used for the assessment of my ill healthretirement application, and which are held by the PSPA, will be considered and all such information willbe made available to the PSPA Pensions’ administrators, their medical advisers, and where necessary, anindependent examining doctor.”“I do not agree that for the purpose of considering my application, the PSPA and or their medicaladvisers can obtain information from my employer, DSC or any doctor or specialist who has beeninvolved in my care that is relevant to this claim, that the documents which were used for theassessment of my ill health retirement application, and which are held by the PSPA, will be consideredand all such information will be made available to the PSPA Pensions’ administrators, their medicaladvisers, and where necessary, an independent examining doctor.”Please tick one of the following choices.Your signature:I agree to attend any medical examinations by an independent doctor if necessary.I do not agree to attend any medical examinations by an independent doctor.Print name:Home address:Home telephone number:Date:/ /Please check the form and make sure you have enclosed everything you want to send us.Send this form and all relevant papers to:PSPA Injury Benefits, Goldie House, 1-4 Goldie Terrace, Douglas ISLE OF MAN IM1 1EB