Injury Benefit Application Form - IoMG Unified Scheme

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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
Page 1: Public Sector Pensions AuthorityInt
Page 5 and 6: Part 2 continued9. Has the employee
Page 7 and 8: BTo be completed by the ApplicantPa
Page 9 and 10: Part 5 continuedTO BE SIGNED IN ALL
Page 11: Part 5 continued9. Please provide d
Page 14 and 15: Part 6We need your consent to acces

Injury Benefit Application Form - IoMG Unified Scheme

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