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DISABLEMENT Claim Checklist

  • Claim Form – N.I. 119. This form is completed upon the loss of physical or mental faculty and includes disfigurement due to a job related incident.
  • ALL fields must be completed. ALL changes MUST be initialed and / or stamped.

Section "A" The form MUST be signed and dated by the applicant.

  • If the insured is unable to sign, the thumbprint will be certified at the NIBTT.
  • If the claim is being submitted by a third party, at the "Particulars of Witness to Mark" the thumbprint should be certified by an approved authority.
  • The insured MUST state clear details of the accident.

Section "C" to be completed by a Registered Medical Practitioner.

  • The insured's name MUST be correctly stated.
  • The date the insured was examined MUST be clearly stated.
  • The effective date, period of the incapacity and percentage MUST be clearly stated. The form MUST be signed, dated and stamped by the Registered Medical Practitioner.
  • The Registered Medical Practitioner's registration number MUST be correctly stated.

Section "D" to be completed by the Employer. (This section should ONLY be completed if an injury application was not previously submitted).

  • The original or certified copy of an accident report may be submitted.
  • Identification Card of the Insured.
  • Original & Copy of the Birth Certificate / Affidavit / Deed Poll / Divorce Decree Absolute where there is a change to the insured's name.
  • If the method of payment is Financial, the bank statement reflecting the name of the bank, the account number and the branch should be submitted. If the method of payment is Postal a utility bill, no older than three (3) months should be submitted.
  • If the claim is being submitted by a third party, the Identification Card of the third party MUST be presented.
  • The claim MUST be submitted within fifty-two (52) weeks from the start date of the incapacity, if not a letter MUST be written with an explanation for the late submission.