Form Med 2 - Claim For Maternity Benefit - The National Insurance Board Page 2
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2Section B: Claimant Details (To be completed by the Claimant)
Section C: Claimant’s Declaration (To be completed by the Claimant)
Note: This claim form MUST be accompanied by a completed Employer’s Certificate (Form Med.4), if you are
I declare that:
currently employed. This claim WILL NOT be processed until the Form Med.4 is received. (The Form Med.4
29. My last day at work was ______________________.
is not required for Self-Employed Persons.) You are encouraged to submit a completed Registration Form
dd/mm/yyyy
(Form R.4) for each live birth as soon as possible after the birth of your child(ren).
30. This is my
First
Second claim for this pregnancy.
6.
Mrs./
Ms. ____________________________________________________________________
Last Name
First Name
Middle Name(s)
31. I do not expect to work for salary or wages in respect of the period for which benefit is being claimed.
7.
N.I.# _________________________________ 8. Date of Birth _____________________________
dd/mm/yyyy
32. I, hereby, claim Maternity Benefit and/or Grant in accordance with the Medical Certificate in Section A.
9.
House # & Street: __________________________________________________________________
33. The information given by me on this form is true and correct to the best of my knowledge and belief.
10. Telephone #1: ________________________
11. Telephone #2: ___________________________
34. Claimant’s Signature: ________________________________________________________________
12. P.O. Box: _____________________ 13. Email Address: __________________________________
OR, if unable to sign,
Employment Details
Agent/Representative’s _____________________________
_____________________________
Name (printed)
Signature
14. Occupation: __________________________________________________________________
15. Are you Self-Employed?
Yes
No (If your response is ‘Yes’ then proceed to question 20)
Date: ______________________________
dd/mm/yyyy
16. Department: __________________________ 17. Supervisor: _____________________________
18. Your Work Employee #: ___________________________
Section D: Explanatory Notes
19. Employer/Company: ________________________________________________________________
20. Employer/Self-Employed N.I.#: _______________________
35. Maternity Benefit is payable for a period of thirteen (13) weeks. Payment of Maternity Benefit will
begin either six (6) weeks before the expected day of confinement or the day you stopped work.
21. Employer/Company Address: _________________________________________________________
36. If you claim the benefit before your baby is born and the actual confinement is delayed, the payment
period may be extended by one (1) week for each week that confinement is delayed.
22. Telephone #1: ________________________
23. Telephone #2: ___________________________
37. Confinement is so defined by the National Insurance (Benefits and Assistance Regulations), that a
certificate can only be given:-
24. P.O. Box: ______________________________ 25. Email Address: __________________________
i. where labour results in the issue of a living child, or
26. Employment History:
ii. where labour results in the issue of a still-born child and pregnancy has lasted for at least
twenty-four (24) weeks.
Previous Employer/Company Name
Start Date (dd/mm/yyyy)
End Date (dd/mm/yyyy)
The certificate must not be given in any other circumstances.
38. Claimants who have paid at least fifty (50) contributions may be entitled to a Grant of four hundred
dollars ($400) when labour results in the issue of a living child.
39. Where a claimant does not meet the contribution condition for the Grant, but her husband meets the
contribution condition for the award of the Benefit, the claimant would be paid the Grant. In this case,
the claim for Maternity Grant (Spouse) (Form Med.3B) must be completed.
27. If you were on vacation during pre-confinement period, please state when: ________ to __________ .
40. For further information about the Maternity Benefit and Grant, please ask for the Maternity Benefit
dd/mm/yyyy
dd/mm/yyyy
leaflet at your nearest Local Office or visit
28. If unemployed during the pre-confinement period, please state date employment ceased: __________
dd/mm/yyyy
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