Continuing Eligibility To Receive A Benefit Form

The National Insurance Act, 1972

Commonwealth of The Bahamas

Continuing Eligibility to

Receive a Benefit

This form must be validated by a “Sanctioned Autority,” i.e., an Officer of the National Insurance Board;

Counsel or Attorney of the Supreme Court; a Public Officer above the rank of Assistant Head of Department;

an ordained Minister of Religion; a Bank Manager; Magistrate; or Justice of the Peace, who is not a member

of the Pensioner’s immediate family. In the case of Pensioners who reside outside The Bahamas, a sanc-

tioned authority may also be a Notary Public, a Lawyer, or a Chief of Police.

I. P

ENSIONER

NFORMATION

Pensioner: ________________________________________________________________________

Surname

First Name

Other Name(s)

Claim No: ___________________ N.I. #:

Tel. No: ______________

Address: __________________________________________________________________________

Street

City /Settlement

P. O. Box/Area Code _______________

E-mail: ________________________________________

Benefit: ________________________ *Bank: _________________

Account # _____________

* If the bank account information indicated above is different from the one previously supplied, be sure to

complete and submit a “Direct Deposit” form.

II. C

HANGE OF

DDRESS

(Complete only if you moved since last verification)

Address: __________________________________________________________________________

House /Apt.#

Street

P.O. Box/Area Code:

_____________________________________________________________________________________________________________

Island/State

Country

Telephone No:_____________________ (H)

_____________________ (W)

III.V

ERIFICATION

Every Pensioner must notify the Director in writing as soon as practicable after the occurrence of any

change of circumstances that may affect his right to Benefit or to the receipt thereof.

Any Pensioner who, without good cause, fails to notify the Director of such Change of Circumstances

will be guilty of an offence and would be liable on summary conviction to a fine not exceeding one

hundred dollars, ($100.00).

A change of circumstance may affect a Pensioner’s entitlement to Benefit.

Although a Pensioner was awarded Benefit, he can be disqualified from further receipt of Benefit/

Assistance if his circumstances change.

Payment of Benefits will be suspended if a pensioner fails to produce evidence of his continuing

eligibility for such payments within the prescribed timeframes.

(Complete only the sections that apply to you)

ETIREMENT

ENEFIT

ERIFICATION

1. Employment Status:

Employed

Self-employed

Unemployed

2. If Employed/Self-employed, how much do you earn Weekly: $__________/ Monthly: $__________

Employer’s Name: _________________ Address: ___________________ Tel: ________________

NVALIDITY

ENEFIT

ERIFICATION

1. Employment Status:

Employed

Self-Employed

Unemployed

B.75b

Continuing Eligibility To Receive A Benefit Form - Nib

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