Injury Benefit Application Form - IoMG Unified Scheme

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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
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Injury Benefit Application Form - IoMG Unified Scheme

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