Detail

Back to Revised Laws of Saint Lucia (2023)

Schedule 1

ARRANGEMENT OF FORMS
FORM R 1
Application Form for Registration by Employer	Regulation 3(1)
FORM R 3
Employed persons application for registration	Regulation 3(2)
FORM CF 1
Change of Address	Regulation 3(4)(a)
FORM CF 2
Cessation of Employment	Regulation 3(4)(b)
FORM C 2
Contribution Remittance Form	Regulation 8
FORM C 3
Monthly Schedule of Contributions	Regulation 9(1)
FORM SE1
Self Employed Persons Application for Registration	Regulation 12(2)
FORM VC 1
Application for registration as Voluntary Contributor	Regulation 12A(6)
FORM SB 2
Claim for Sickness Benefit	Regulation 31
FORM Inv.B1
Claim for Invalidity Benefit	Regulation 38
FORM MB1
Claim for Maternity Allowance and Grant	Regulation 44(1)
FORM MB2
Claim for Maternity Grant	Regulation 44(2)
FORM Sur.B1
Claim for Survivors/Death Benefit	Regulation 46(7)
FORM RB 1
Claim for Age Benefit	Regulation 58(1)
FORM NI/LC
Life Certificate	Regulation 58(2)
FORM FB 1
Claim for Funeral Benefit	Regulation 61(3)
FORM EIB 1
Notice of Employment Injury	Regulation 64
FORM EIB 2
Claim for Employment Injury Benefit	Regulation 66
FORM DB 1
Claim for Disablement Benefit	Regulation 70(2)
FORM APP1
Notice of Appeal	Regulation 112(2)
TABLE I
Wage Bands for Self Employed Contributors	Regulation 12(8)
TABLE II
Qualifying No. of Months for Pensions	Regulation 35
TABLE III
Insurable Earnings on Income in Excess of $36,000 per Annum	Regulation 36
TABLE IV
Early Retirement Pension Formula	Regulation 55(2)
TABLE V
Amount of Funeral Grant	Regulation 61(2)

FORM R1
(Reg. 3(1))
			FOR OFFICE USE ONLY				REGISTRATION NO.
APPLICATION FOR REGISTRATION BY EMPLOYER
A.	TO BE COMPLETED BY ALL EMPLOYERS
	1.	Name of Owner/Trustee: ............................................................
	2.	Nat. Ins. Reg.# (Employer of Household help): ........................
	3.	Trade of Business Name ............................................................
	(If different from 1 above)
		(If Business is registered a Copy of Certificate of Registration must be produced)
	4.	Name of Company: ....................................................................
		(A copy of Certificate of Incorporation, Notice of Directors and Notice of Registered Office must be produced)
	5.	Postal Address ............................................................................
	6.	Location of Business ..................................................................
	7.	Nature of Business .....................................................................
		(Indicate major activity)
	8.	Number of Employees: ...............................................................
	9.	Business Telephone Number: .....................................................
	10.	Business Fax Number: ................................................................
	11.	E-mail Address: ..........................................................................
	12.	Previous Business Owned: .........................................................
	13.	Name of Associated Companies: ................................................
	14.	Location of Branches/Divisions: ................................................
B.	TO BE COMPLETED FOR ALL EXTERNAL COMPANIES
	1.	Name of Head Office/Parent Company ......................................
	2.	Jurisdiction of Incorporation .......................................................
	3.	Address of registered Office		(a)		Local .............................
				(b)		External ........................
Name and Position of Applicant ....................................................................
(Please Print)
Signature of Applicant ................................					Date .....................................
* Where the application is made in respect of domestic employment the residence address should be given and the nature of business should be shown as “household”.

FORM R3

(Reg 3(2))

APPLICATION FOR REGISTRATION

FOR OFFICIAL USE ONLY

NAT. INS. NO ALLOTTED

DO NOT COMPLETE THIS FORM

IF YOU HAVE COMPLETED ONE BEFORE.

(USE BLOCK LETTERS)

Name ..............................................................................................................

Surname

Other names

Also known as (alias) ....................... (If married give maiden name) ...........

Date of Birth (Day) ......................... (Month) .................... (Year) ...............

Place of Birth .................. Nationality ................ National Reg. No. ............

Passport No ................ Place of Issue ...................... Date of Issue ..............

Address ...........................................................................................................

District ........................................ Occupation ...............................................

Purpose of Registration .......................................... Tel # ..............................

Mark with X as Appropriate

Sex of Applicant

Male

Female

Marital Status of Applicant

Married

Single

Widow

Widower

Divorced

Separated

Spouse Name ....................................................

FOR OFFICIAL USE ONLY

Date of Marriage ...............................................

Other Verification

Passport

Signature of Applicant ................. Date ...........

Birth Certificate

(Witnessed by an Employee of the NIC)

Initial

Signature of Witness .................. Date .............

Date

THIS SECTION MUST BE COMPLETED BY EMPLOYER

Name of Employer .........................................................................................

Registration Number of Employer .................................................................

Address of Employer .....................................................................................

Nature of Business ............................................ Sector .................................

Date of Commencement of Employment ......................................................

Signature of Employer or his or her representative..................... Date ...........

Notes

FOR OFFICIAL USE ONLY

Return this Form as soon as it is completed with Birth Certificate or Passport.

Entered Date ............ Intl ........

No Employee should be Employed without a National Insurance Card.

Verified Date ............ Intl .......

NATIONAL INSURANCE SAINT LUCIA

INSURED PERSON'S CONTRIBUTION AND BENEFIT RECORD

FORM R6 R 14

SURNAME .....................................................................

CHRISTIAN NAMES .....................................................................................

(Block Capitals)

alias...........................................................................

ADDRESS ...............................................................................................................

SEX

..........................................................................................................................

Nat. Ins. No.

.....................................................................................................................

Date of entry into Scheme

Date of Birth

If verified enter “V”

Date of Marriage

If verified enter “V”

Ent'd ......................ch'd ...............................

Ent'd ................ch'd ................

CONTRIBUTION RECORD

Checked

Employers Numbers

Year

Jan

Feb

Mar

Apr

May

June

July

Aug

Sep

Oct

NOV

Dec

Total

Date

Intls

Paid

Credit

Paid

Credit

CONTRIBUTION RECORD

Checked

Employers Numbers

Year

Jan

Feb

Mar

Apr

May

June

July

Aug

Sep

Oct

NOV

Dec

Total

Date

Intls

Paid

Credit

Paid

Credit

BENEFIT RECORD

Date

Initials

BENEFIT RECORD

Date

Initials

NOTES

Kind

From

Amount

Kind

From

Amount

FORM CF 1
(Reg 3(4)(a))
CHANGE OF ADDRESS
(EMPLOYER OR EMPLOYER'S REPRESENTATIVE TO COMPLETE IN BLOCK LETTERS)
Business Name ...............................................................................................
Registration #: ...............................................................................................
New Address:
Business Address ............................................................................................
......................................................................................................................
Postal Address: (if different) ............................................................................
......................................................................................................................
......................................	....................................	...............................
Authorised Signature	Name (Please Print)	Position
.........................................................
Date

FOR OFFICIAL USE:
..........................................................
Updated by Customer Service Clerk
..........................................................
Date

FORM CF 2
(Reg. 3(4)(b)
STATEMENT FROM EMPLOYER TO CONFIRM CESSATION OF EMPLOYMENT
Employer's Name .........................................................................................
Registration No. ............................................. Date ......................................
The Director
National Insurance, Castries
Dear Sir/Madam
I/We hereby inform you that there was/will be a cessation of employment in my/our business from ..........................................................
I/We will resume/resumed employment by/on ..............................................
Reasons for cessation
Yours sincerely
...................................		...........................................			............................
Director/Manager (Please Print Name)		Employer Signature & Stamp			Date
FOR OFFICIAL USE ONLY
To Be Completed By An Inspector				To Be Completed By Compliance Clerk
Wage Records Examined: Yes No				Code Assigned
If No, Please state method of verification: ............................................................. ............................................................. .............................................................				................................... Name
Other Comments ............................................................. ............................................................. .............................................................				................................... Signature
.............................. .........................				.......................................... Date
Inspector's Signature	Date
Review 1
Inspectors comments/verification performed (to be completed at closure date or end of dormancy period)
Recommendation:			Code Assigned
			Name ..............................
Inspector's Signature ..........................			Signature ..............................
Date ..............................			Date ..............................
Review 2
Inspectors comments/verification performed (to be completed at closure date or end of dormancy period)
Recommendation:			Code Assigned
			Name ..............................
Inspector's Signature ..........................			Signature ..............................
Date ..............................			Date ..............................

FORM C2
(Reg. 8)
DUE AND
PAYABLE IN	(Insert Month here)
CONTRIBUTIONS REMITTANCE FORM
(To be printed in Duplicate)
This form with a remittance for the total contributions due in ___________ must reach the office not later than 7 days after the end of the month for which it is due.
		EMPLOYER'S REG. NO.
		_____________________________
Name of Employer _____________________________________________
Address of Employer ___________________________________________
I certify that the amounts shown below represent the total contributions due and payable and which are shown on the Form C3.
No. of Employees _____________________________________________
Contributions for month ending __________________ $ ______________
1.25% surcharge for late remittance			$ _____________
(If Applicable)
		Total $ _______________________
Signature _____________________		Date _____________________

FOR OFFICIAL USE ONLY
Checked by ___________________________________
Date _________________________________________
Posted to Employer's ledger by ____________________
Verified by _____________________ Date __________
Contributions due and payable in _______________________
(State month)

FORM C3
(Reg. 9(1))
MONTHLY SCHEDULE OF CONTRIBUTIONS
SCHEDULE OF CONTRIBUTIONS FOR MONTH OF ________ TO BE SUBMITTED WITH REMITTANCE FOR ______________________ TOTAL CONTRIBUTIONS DUE IN __________________________ TO REACH NIC OFFICE NOT LATER THAN 7 DAYS AFTER END OF MONTH					EMPLOYER NUMBER ______ & NAME __________________ PAGE
Total Brought Forward from Previous Sheet (If Any) =
EMP. NIC No.		Employee Name	Contribution	EMP.NIS No.		Employee Name		Contribution

			DELETE AS NECESSARY			A. Total carried for-ward to next sheet
						B. Total for which payment is sent
Please make note of the following:
1.	If the N.I..C Number for any employee is incorrect or missing, please insert the correct number.		I CERTIFY THAT THE AMOUNTS SHOWN REPRESENT TOTAL CONTRIBUTIONS DUE AND PAYABLE.
2.	Insert the Total Contribution to be paid on behalf of each employee. This is twice the amount deducted from his/her salary.		__________________				______________
3.	The Grand Total on this form must equal the value of your payment. Return this form to the N. I.C Office at the end of every month.		Signature and Stamp of Employer/Agent				Date
			FOR OFFICIAL USE ONLY
4.	Penalty fee of 1.25% will be charged for late submission of Contribution Payment		RECEIVED: DATE ____________ INT _______ ENTERED: DATE ____________ INT _______ VERIFIED DATE ___________ INT ______
5.	Delete the name and number of persons no longer employed.
6.	Add NIC Number and full name of any new employees.
7.	Return white copy of this form to NIC Office.

SAINT LUCIA

Form C 4

NATIONAL INSURANCE

R 19(1)

Schedule of Contributions for Half Year Ending

Employer's Number

Name and Address

Sheet No

30 June 20————

To be Retained and Submitted with Employer's Deduction Card to Reach the N.I.S. on or Before 31 December

Telephone No.

Contributions Paid in Respect of Month of

Name as Copied from Employee's Deduction Card

National Insurance No.

Jan

Feb

Mar

Apr

May

June

Total

Office Use

Entry No.

$ c.

Delete as Necessary

For Official use Only

Signature and/or

Stamp of Employer or Agent________________

Received

Checked

Date

Initials

Date

Sig.

Posted to Ledger Sheets by

Verified by

Date

Initials

Date

Sig.

Designation _______________

Date ________

FORM SE1
(Reg. 12(2))
SELF-EMPLOYED PERSONS APPLICATION FOR REGISTRATION
						National Insurance No.

In accordance with regulation ________________ of the National Insurance Regulations 2001 I hereby apply for registration as a self-employed person and submit hereunder the following relevant particulars:
1.	Name __________________________________________________
	Surname		Other Names
2.	Address and Telephone Nos. ________________________________
3.	Date of Commencement of __________					________	_________
	Trade or Business	Day				Month	Year
4.	Declared Earnings for Year ended 31 December _______ $ ______
5.	Details of Earnings _______________________________________
6.	Nature of Trade or Business ________________________________ ________________________________________________________
	________________________				______________________
	Signature of Applicant				Date
7.	Annual Insurable Earnings for the year ending 31 December ____________ $ ___________
8.	Assessed Annual Insurable Earnings $ ___________________
9.	Assessed Monthly Contribution					$ ___________________
	____________________			_________________________
	Date			Signature of Insured Person
9.	Application and Assessment Approved By: ____________________
				Signature of National Insurance Corporation Official
				__________________________
				Date

FORM VC 1
(Reg. 12A(6))
APPLICATION FOR REGISTRATION – VOLUNTARY CONTRIBUTORS
Name ...........................................................................................................
Also known as (alias) .....................................................................................
National Insurance Number ............................................................................
Sex (Male/Female) ................. Marital Status(Married/Single) ...................
Date of Birth (Day/Month/Year) .......................... Nationality ......................
(Birth Certificate or Passport to be submitted)
Address ........................................ ..................................................		Country of Residence .......................
Name of Last Employer .................................................................................
Purpose of Registration ..................................................................................
...........................................................			.....................................
Signature of Applicant			Date
Where the claimant cannot sign, a responsible person (Lawyer, J.P.. Doctor, Senior Civil Servant on permanent establishment, etc.) should witness the Mark by signing below.
........................................................		.........................................
Name of Witness (please Print)		Signature
..........................................................		........................................
Occupation		Date
FOR OFFICIAL USE ONLY
(i)	Number of Contributions paid .................. (minimum of 60 months)
(ii)	Date of last contribution ....................................................................
(iii)	Average annual wage for 20____ and 20____ $ ............................ (for last 2yrs worked)
(iv)	Contribution required per month $.......... (min of 5%, max of "10% of (iii) above)
Signed ..........................................................

FORM SB2
(Reg. 31)
CLAIM FOR SICKNESS BENEFIT
I, the undersigned, hereby apply for sickness benefit under the National Insurance Corporation Act, 2000 and furnish a Medical Certificate, together with the following particulars:
My full name is _______________________________________________
(Please Print)
My Nat. Ins. No. is ____________________________________________
Date of Birth _________________________________________________
My Address is ________________________________________________
Tel. No. _____________________________________________________
When I became ill I was employed by ______________________________
My occupation was ____________________________________________
I finished working there on ______________________________________
I understand that a False Statement or Misrepresentation makes me liable to a penalty under the National Insurance Corporation Act.
Date _________________					____________________________
					Signature or Mark of Claimant
NOTE:		Where the Claimant cannot sign, a responsible person (Lawyer, J.P., Doctor, Senior Civil Servant on permanent establishment, etc.) should witness the Mark by signing on the line below.
			Witness to Mark ___________________________
			Profession or Occupation _____________________
			Address __________________________________
			Date _____________________________________
TO BE COMPLETED BY EMPLOYER:
1.	Name of Employer and Registration No. ______________________
2.	Tel. No. ________________________________________________
3.	The above named employee has been absent from work continuously since _________ on account of ______________________________
4.	This Employee has been/will be paid wages/salary at the rate of ___________ per week/month, during the period of absence from work up to and including __________________________________
	(Insert last date from which wages/salary will be paid if absence continues)
	I certify that the above statements are true to the best of my knowledge and belief and I assume full responsibility as to their correctness. I also undertake to notify the National Insurance Corporation as soon as possible, of the return of the employee to my employ.
Date ______________				Signature ___________________________
				Print Name __________________________
				Position ____________________________
				Stamp ______________________________
MEDICAL CERTIFICATE – SICKNESS
IN CONFIDENCE TO:
Mr./Mrs./Miss ________________________________________________
(Print Name)
I ______________________________________________________ a duly
Qualified Registered Medical Practitioner, hereby certify that in my opinion you were at the time of my examination suffering from:
________________________________________________________________________________________________________________________
As a result of this illness you will
(1)	Remain incapable of work for a period of _______________ days commencing on ____________________________
(2)	You will be fit to resume work today/tomorrow/on ______________
	Any Other Remarks by Doctor ______________________________
	_______________________________________________________
Doctor's Name _______________________________________________
(in Block Letters)
Doctor's Signature ________________						Date ___________________
Address _____________________________________________________
Tel. No. _____________________________________________________

Form Inv. B1
(Reg.38)
CLAIM FOR INVALIDITY BENEFIT
I hereby apply for Invalidity Benefit under the National Insurance Corporation Act, 2000 and furnish a medical certificate and other supporting documents together with the following particulars:
1.	My full name is ___________________________________________
	(Print Name)
2.	Occupation _______________________________________________
3.	My Nat. Ins. No. is _________________________________________
4.	My date of birth is _________________________________________
5.	My address is _____________________________________________
6.	My Tel. No. is ____________________________________________
7.	My last/present Employer's name and address were/are
	Name of Employer _________________________________________
	Address _________________________________________________
	Tel. No. _________________________________________________
	Period of Employment ______________________________________
8.	The Name and Address of the last Doctor who examined me is/was:
	Name of Doctor ___________________________________________
	Address of Doctor _________________________________________
	Tel. No. _________________________________________________
ANSWER ALL QUESTIONS
(a)		From what date have you been continuously incapable of work? _________________________
(b)		What is the nature of your illness or disease? ___________________
(c)		Are you now receiving sickness or any other benefit? ____________
(d)		If so, from what date have you been receiving such benefit? _________________________
I declare that the foregoing information is true in all particulars. I understand that a false statement or misrepresentation makes me liable to a penalty under the National Insurance Corporation Act,.
If unable to sign, mark X and have it witnessed by a responsible person (Lawyer, J.P., Doctor, Senior Civil Servant on permanent establishment, etc.)
____________________						__________________________
Date						Signature or mark of Claimant
				Witness to mark ________________________
				Profession or Occupation _________________
				Address ______________________________
				Date _________________________________
MEDICAL CERTIFICATE OF PERMANENT INCAPACITY FOR WORK
(To be completed by a Registered Medical Practitioner)
To: Mr./Mrs./Miss _____________________________________________
(Print Name)
I hereby certify that on _____________________________ 200_________
I examined you and found that you are suffering from ____________
____________________________________________________________
(state nature of disease or bodily or mental disablement)
A disablement which is likely to remain permanent.
In my opinion you are likely to remain permanently incapable of work as a result of this disablement.
			Yes				No	(Tick appropriate box)
Give reasons for Claimant's condition: _____________________________
					Signature __________________________
					Name _____________________________
					(Please Print)
					Address ___________________________
					Date ______________________________
					Tel. No. ___________________________
NOTE
For purposes of a “benefit” under the National Insurance Regulations 2000 the term “Invalid” means a person incapable of work as a result of a specific disease or bodily or mental disablement which is likely to remain permanent, and the term “disablement” means a loss of capacity for any of the ordinary activities of life.

FORM MB1
(Reg. 44(1))
CLAIM FOR MATERNITY ALLOWANCE AND GRANT
(In accordance with the National Insurance Corporation Act).
I hereby apply for Maternity Benefit under the National Insurance Corporation Act, and furnish a Certificate of Expected/Actual Confinement, together with the following particulars:
My full name is _______________________________________________
(Print Name)
My Nat. Ins. No. is ____________________________________________
My address is _________________________________________________
My Tel. No. is ________________________________________________
My Date of Birth is ____________________________________________
I am/was employed by __________________________________________
I last worked there on ___________________________________________
The period for which I claim benefits is from _____________ to ________
I do not expect to receive any wages or salary from my Employer during my absence from work. I will be given ____________________ weeks Maternity Leave, from ________________ to __________________ during which period I will be paid __________________ per week/month.
I understand that a False Statement or Misrepresentation makes me liable to a Penalty under the National Insurance Corporation Act, 2000.
____________________					____________________________
Date					Signature or Mark of Claimant
NOTE:		Where the Claimant cannot sign, a responsible person (Lawyer, J.P., Doctor, Senior Civil Servant on permanent establishment, etc.) should witness the mark by signing on the line below.
			Witness to Mark ___________________________
			Profession or Occupation _____________________
			Address __________________________________
			Date _____________________________________
TO BE COMPLETED BY EMPLOYER:
1.	Name of Employer and Registration No. ______________________
2.	Tel. No. ________________________________________________
3.	The above named employee has been absent from work continuously since _________ on account of ______________________________
4.	This Employee has been/will be paid wages/salary at the rate of ___________ per week/month, during the period of absence from work up to and including __________________________________
(Insert last date from which wages/salary will be paid if absence continues)
I certify that the above statements are true to the best of my knowledge and belief and I assume full responsibility as to their correctness. I also undertake to notify the National Insurance Corporation as soon as possible of the return of the employee to my employ.
Date ______________				Signed ___________________________
				Employers Signature
				Print Name __________________________
				Position ____________________________
				Stamp ______________________________
MEDICAL CERTIFICATE OF EXPECTED/ACTUAL CONFINEMENT
(TO BE GIVEN BY A REGISTERED MEDICAL PRACTITIONER OR REGISTERED MIDWIFE)
(A or B to be completed as appropriate)
To:
M ______________________________________________________
(Print Name)
A. EXPECTED CONFINEMENT
I certify that I examined you on __________________________________ and that in my opinion you may expect to be confined on the ______________ day of _____________________________ 20________
Any other Remarks by Doctor or Midwife ______________________
____________________________________________________________
B. ACTUAL CONFINEMENT
I certify that I attended to you during your confinement which took place at _____________________ on the ______________ day of _____________
						CHILD	LIVING
And that you delivered: Male/Female						_______	________
						CHILDREN	DEAD
Name of Doctor or Midwife _____________________________________
(Block Letters)
Signature and Stamp ___________________________________________
Address _____________________________________________________
Tel. No. _________________________
Date ____________________________

FORM MB 2
(Reg. 44(2))
CLAIM FOR MATERNITY GRANT
(For Claims Based on Contribution Record of Husband)
I hereby claim Maternity grant on my husband's/common law husband's contribution and furnish a Certificate of Confinement and marriage certificate where applicable together with the following particulars:
My full name is _______________________________________________
(Block Letters)			Surname		Other Names
My Nat. Ins. No. is ____________________________________________
My Date of Birth is ____________________________________________
My Tel. No. is ________________________________________________
My Address is ________________________________________________
My Husband's/Common Law Husband's Name is ____________________
His N.I.C. No. is ______________________________________________
His Address is ________________________________________________
He was/is employed by _________________________________________
His Occupation is _____________________________________________
His Employer's Address is ______________________________________
I hereby declare that I have lived with the said Mr. _________________________ as his wife/common law wife from the ___________________________ day of _________________ 20_______
___________________				____________________________
Date				Signature Mark
NOTE:	Where the Claimant cannot sign, a responsible person (Lawyer, J.P., Doctor, Senior Civil Servant on permanent establishment, etc.) should witness the mark by signing on the line below.
		Witness to Mark ___________________________
		Profession or Occupation _____________________
		Address __________________________________
		Date _____________________________________

Form Sur. B 1

(Reg. 46(7), 78(1))

CLAIM FOR SURVIVOR'S/DEATH BENEFIT

I hereby apply for Survivor's/Death Benefit under the National Insurance Corporation Act, 2000, and furnish a Death Certificate and other supporting documents together with the following particulars:

PARTICULARS OF DECEASED

Name of Deceased Person __________________________________

(Block Letters)

Surname

Other Names

Nat. Ins. No. _____________________________________________

Date of Birth ____________________________________________

Day

Month

Year

Date of Death ____________________________________________

Day

Month

Year

Was Death due to an Employment Injury/Disease? Yes/No

If not, state cause of death __________________________________

Was deceased in receipt of any benefit from National Insurance Corporation? Yes/No

State what Benefit ________________________________________

Name of Employer prior to death and duration of such Employment ________________________

10.

Address of Employer ______________________________________

11.

Tel. No. of Employer ______________________________________

PARTICULARS OF CLAIMANT

Name of Claimant ______________________ Nat. Ins. No. _______

(Block Letters)

Surname

Other Names

Date of Birth of Claimant __________________________________

Day

Month

Year

Relation to Deceased ______________________________________

(If Widow or Widower attach Marriage Certificate)

Address of Claimant ______________________________________

Was Claimant wholly or mainly maintained by the deceased person? _________________________________________

Was Claimant residing with deceased at the time of death? Yes/No

Tel. No. ________________________________________________

GIVE PARTICULARS OF THE CHILDREN OF THE DECEASED PERSON

Name of child/Children

Sex M/F

Father's Name

Mother's Name

Date of Birth

Place of Birth

(ATTACH THE BIRTH CERTIFICATE OF EACH CHILD UNDER 18 YEARS)

I hereby declare that I have lived with the said ___________________ now deceased as *Husband/Wife/Common Law Husband/Common Law Wife from the ___________________ day of _______________________.

Signature/Mark __________________

Date ___________________________

I declare that the foregoing information is true in all particulars. I understand that a false statement or misrepresentation makes me subject to a penalty under the National Insurance Corporation Act 2000.

____________________

_____________________________

Date

Signature or Mark of Claimant

If unable to sign, mark X and have it witnessed by a responsible person (Lawyer, J.P., Doctor, Senior Civil Servant on permanent establishment, etc.)

Signature _________________________________

Name of Witness ___________________________

Profession or Occupation _____________________

Address __________________________________

Date _____________________________________

Form RB 1
(Reg. 58)
CLAIM FOR RETIREMENT BENEFIT
I hereby apply for Retirement Benefit under the National Insurance Corporation Act, 2000, and furnish my Birth Certificate and other supporting documents together with the following particulars:
PARTICULARS OF CLAIMANT
My full name is _______________________________________________
(Print Name)
My Nat. Ins. No. is _____________________________________________
My date of birth is _____________________________________________
My address is _________________________________________________
My last/present Employer's name and address were/are ________________
Name of Employer _____________________________________________
Address _____________________________________________________
I declare that I have reached the age of ____________ will reach the age of _____________ on the ____________________ day of _______________ 200 ________ I further declare that I am continuing in employment/retired from gainful employment.
I understand that a False statement or Misrepresentation makes me liable to a penalty under the National Insurance Corporation Act.
____________________		_____________________________
Date		Signature or mark of Claimant
If unable to sign, mark X and have it Witnessed by a responsible person (Lawyer, J.P., Doctor, Senior Civil Servant on permanent establishment, etc.)
	Signature ____________________________
	Name of Witness ______________________
	Profession or Occupation ________________
	Address _____________________________
	Date ________________________________

Form FB 1
(Reg. 61(3))
CLAIM FOR FUNERAL GRANT
I hereby apply for Funeral Grant under the National Insurance Corporation Act, and furnish a Death Certificate and receipts in support of funeral expenses together with the following particulars:
1.	Name of deceased person ___________________________________
2.	Nat. Ins. No. _____________________________________________
3.	Date of Birth ____________________________________________
4.	Date of Death ____________________________________________
5.	Cause of Death ___________________________________________
6.	Name of Claimant ________________________________________
7.	Tel. No. ________________________________________________
8.	Date of Birth ____________________________________________
9.	Relation to deceased ______________________________________
10.	To the best of your knowledge and belief, are you the only person who will be entitled to make this claim? _______________________
11.	Nat. Ins. No. _____________________________________________
I declare that the foregoing information is true in all particulars. I understand that a false statement or Misrepresentation makes me liable to a penalty under the National Insurance Corporation Act.
____________________			_____________________________
Date			Signature or Mark of Claimant
If unable to sign, mark X and have it Witnessed by a responsible person (Lawyer, J.P., Doctor, Senior Civil Servant on permanent establishment, etc.)
		Signature of Witness ___________________
		Name of Witness ______________________
		Profession or Occupation ________________
		Address _____________________________
		Date ________________________________

Form EIB 1

(Reg. 64)

NOTICE OF EMPLOYMENT INJURY

Employer's Reg. No.

PARTICULARS OF UNDERTAKING

Name of Employer _______________________________________

Address of work place or place where accident occurred ________ _______________________________________________________

Nature of business ________________________________________

Tel. No. ________________________________________________

PARTICULARS OF INJURED PERSON

Surname ___________________ First name ___________________

Alias or other names ______________________________________

Date of Birth ______________ Sex _______ Nat. Ins. No. ________

Full address _____________________________________________

Tel. No. ________________________________________________

Occupation or title ________________________________________

Nature and location of injury ________________________________

Estimated duration of disability ______________________________

(on basis of Medical Certificate)

Normal rate of wages ______________________________________

(a)

State wages paid for day of accident (if any)

(b)

How much will injured person be paid per week/month when off work?

$ _________

(c)

For how long will payment be made? From _______________________ to _________________

(d)

Duration of employment ______________________________

CIRCUMSTANCES OF ACCIDENT

Date and hour of accident __________________________________

Day

Month

Year

Time

Date and time injured person stopped working __________________

Day

Month

Year

Time

Between what hours was injured person normally expected to work? From ________________________ to ______________________.

Was the accident reported (Yes/No) __________________________

If Yes, to whom __________________________________________

Exact place or location where accident occured? _____________________

Was the injured person authorised to be in that place at the time of the accident? *Yes/No

Exact type of work performed by injured person at the time of accident ________________________________________________

Was this type of work authorised or permitted? Yes/No

What was the exact cause of the alleged accident? How did it happen? ________________________________________________ ________________________________________________________ ________________________________________________________

10.

If caused by machinery, give name of machine and part causing accident ________________________________________________

11.

State whether machine was moved by mechanical power at time of accident? _______________________________________________

12.

What was the nature, location and extent of the injury observed at the time of the accident? ______________________________________

13.

State whether accident was fatal or not ________________________

14.

State what measures were taken to prevent recurrence of similar accident ________________________________________________

15.

Was accident reported to the Labour Department? Yes/No ________

16.

Could the accident have been prevented? Yes/No _______________

I certify that the information given above is true and correct to the best of my knowledge and I understand that any false statement or misrepresentation renders me liable to a penalty under the National Insurance Corporation Act.

_____________

__________________________________________

Date

Signature and stamp of Employer/Representative

Form EIB 2
(Reg. 66)
CLAIM FOR EMPLOYMENT INJURY BENEFIT
I hereby apply for Employment Injury Benefit under the National Insurance Corporation Act, 2000, and furnish a Medical Certificate together with other supporting documents, and the following particulars:
My full Name _________________________________________________
(Block Letters)		Surname				Other Names
My Date of Birth is ____________________________________________
Day					Month		Year
My Nat. Ins. No. is _____________________________________________
My Employer is _______________________________________________
My Occupation is ______________________________________________
My Tel. No. is ________________________________________________
As a result of my injury, I last worked on ___________________________
I understand that a False Statement or Misrepresentation makes me liable to a Penalty under the National Insurance Corporation Act.
____________________				_____________________________
Date				Signature or Mark of Claimant
NOTE:	Where the Claimant cannot sign, a responsible person (Lawyer, J.P., Doctor, Senior Civil Servant on permanent establishment, etc.) should Witness the Mark by signing on the Line below.
			Witness to Mark _______________________
			Profession or Occupation ________________
			Address _____________________________
			Date ________________________________
MEDICAL CERTIFICATE-INJURY
*In Confidence To:*
Mr./Mrs./Miss ________________________________________________
I __________________________________ a duly qualified Registered Medical Practitioner, hereby certify that in my opinion you were at the time of my examination suffering from ________________________________
As a result of this illness you will
(1) Remain incapable of work for a period of ___________________ ^* In the case of a First Certificate, the days indicated must not be more than 7 (including Sundays and Public Holidays).In the case of a Second Certificate, the days indicated must not be more than 14 (including Sundays and Public Holidays) and for a Third or Subsequent Certificate, the day indicated must not be more than 28.days commencing on ____________________________________________
(2) You will be fit to resume work today/tomorrow/on ________________
Any other Remarks by Doctor __________________________________ ____________________________________________________________
Doctor's Name _______________________________________________
(in block letters)
Doctor's Signature _____________________________________________
Date ________________________________________________________
Address _____________________________________________________
Tel. No. _____________________________________________________

Form DB 1
(Reg. 70(2))
CLAIM FOR DISABLEMENT BENEFIT
I hereby apply for Disablement Benefit under the National Insurance Act, and furnish an assessment of my disablement together with the following particulars:
My Name is __________________________________________________
Surname			Other Names
My NIC No. is ________ My Date of Birth is _________ Tel No. _______
My Address __________________________________________________
Date of Accident Resulting In Disablement _________________________
Nature of Injury _______________________________________________
Name of Employer Where Accident occurred ________________________
I understand that a false statement or misrepresentation makes me liable to a penalty under the National Insurance Corporation Act.
_______________________________		_______________________
Signature of Claimant		Date
Where the claimant cannot sign, a responsible person (Lawyer, J.P., Doctor, Senior Civil Servant on permanent establishment, etc.) should witness the Mark by signing below.
_______________________________		______________________
Signature of Witness		Name (Please Print)
_______________________________		______________________
Occupation		Date

FOR OFFICIAL USE ONLY
Period of E.I.B. ___________________ to _________________________
Amount of E.I.B. $ ____________________________________________
Report of Inspector attached (Yes/No) _____________________________
MEDICAL CERTIFICATE OF ASSESSMENT OF DISABLEMENT
(TO BE COMPLETED BY A REGISTERED MEDICAL PRACTITIONER)
TO: Mr/Mrs/Miss ______________________________________________
Print Name
I hereby certify that on ___________________ 20_________ I examined you and in my opinion you were at the time of my examination suffering from ________________________________________________________
Description of Injury
Per Centum degree of disablement ______________% Serial No.______ (as per to Prescribed Degree of Disablement in Schedule 2 of the National Insurance Regulations)
NB
1.	In the case of a right handed person, an injury to the right arm or hand and in the case of a left handed person to the left arm or hand, shall be rated 10% higher than the above average.
2.	In the case of a post traumatic shortening in a lower limb, any disability of that limb shall be rated at 10% higher than the percentage of that disability.
Signature and Stamp ___________________________________________
Name (please print) __________________ Registration date ___________
Address _____________________________________________________
Date ___________________ Tel Number __________________________

Form NI/LC
(Reg. 58(2) & 107(2))
LIFE CERTIFICATE
Full Name of Pensioner/Beneficiary __________________________________________
Type of Pension _____________ Nat. Ins. No. (Pensioner) _____________
Nat. Ins. No. (Beneficiary) ____________
⁺ Guardian must sign on behalf of a minor child. Signature/Mark of Pensioner/Beneficiary ___________________ Date _________________
I, ___________________________ of _____________________________
(Please Print Name)
^* To be certified by a Notary Royal, Notary Public, Lawyer, Justice of the Peace, Doctor, Senior Civil Servant on permanent establishment, Minister of Religion.___________________________________________________________
(Please State Profession and/or Official Title)
Hereby certify that _____________________________________________
Whose signature is affixed above was alive on the ___________________ day of ___________________________ 20___________
______________________	_______________________
Date	Signature

NOTICE OF APPEAL
Form APP 1
(Reg. 112(2))
No. 20__________
In the matter of _______________________________________________
Print name of Insured person and Nat. Ins. No.
To the Chairperson of the National Insurance Board
cc. The Director of the National Insurance Corporation
I _________________________________________________________ of
(Print Name)
__________________________________________________________ do
Address
hereby give you and each of you notice that it is my intention to appeal against a decision of the Director given on __________________ in respect of an application made by me for a ________________________________ benefit under the National Insurance Corporation Act, and the National Insurance Regulations.
My Nat. Ins. No. is _________________________________________
The general grounds of Appeal are that—
1.	_______________________________________________________
2.	_______________________________________________________
3.	_______________________________________________________
4.	_______________________________________________________
5.	_______________________________________________________
6.	_______________________________________________________
	Dated this ______________ day of _____________ 20____.
	_______________________________________
	Signature

TABLE I

(Reg. 12(8))
WAGE BANDS FOR SELF EMPLOYED CONTRIBUTORS
CATEGORY	MONTHLY INCOME AS A PERCENTAGE OF MAXIMUM INSURABLE EARNINGS
Special	10%
A	20%
B	30%
C	40%
D	50%
E	60%
F	70%
G	80%
H	90%
I	100%

TABLE II

(Reg. 35)
Qualifying No. of Months for Pensions
During the year (s)	Qualifying No. of Months of contribution for pensions
1 January 2000 to 31 December 2002	132 months
1 January 2003 to 31 December 2005	144 months
1 January 2006 to 31 December 2008	156 months
1 January 2009 to 31 December 2011	168 months
1 January 2012 and continuing	180 months

TABLE III

(Reg. 36)
INSURABLE EARNINGS ON INCOME IN EXCESS OF $36,000.00 PER ANNUM
FOR THE YEAR	AMOUNT TO BE CREDITED $
January to December 2001	36,000 + 25% of (excess over 36,000)
January to December 2002	36,000 + 25% of (excess over 36,000)
January to December 2003	36,000 + 30% of (excess over 36,000)
January to December 2004	36,000 + 40% of (excess over 36,000)
January to December 2005	36,000 + 50% of (excess over 36,000)
January to December 2006	36,000 + 60% of (excess over 36,000)
January to December 2007	36,000 + 60% of (excess over 36,000)

TABLE IV

(Reg. 55(2))
EARLY RETIREMENT PENSION FORMULA
Early Retirement Age	: 60
Required months of contributions	: See TABLE 1 of Schedule 1
Early Reduction Factor	: 0.5% per month of age below normal pensionable age
Early Pension Formula	: Full pension at pensionable age X (100-early reduction factor)

TABLE V

(Reg. 61(2))
AMOUNT OF FUNERAL GRANT
Age of Death	Amount of Grant
Under 2 years	$150.00
3 years	$300.00
4 years	$450.00
5 years	$600.00
6 years	$750.00
7 years	$900.00
8 years	$1,050.00
9 years	$1,200.00
10 years	$1,300.00
11 years and older	$1,500.00