Injury Benefit Application Form - IoMG Unified Scheme

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.