Injury Benefit Application Form - IoMG Unified Scheme

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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 <strong>Injury</strong> 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/ // // // // // // /
Page 1 and 2: Public Sector Pensions AuthorityInt
Page 3: Part 2 continued5. Please provide d
Page 7 and 8: BTo be completed by the ApplicantPa
Page 9 and 10: Part 5 continuedTO BE SIGNED IN ALL
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Page 14 and 15: Part 6We need your consent to acces

Injury Benefit Application Form - IoMG Unified Scheme

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