Form Med 1 - Medical Certificate Of Incapacity For Work Page 2
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1
2Section B: Claimant Details (To be completed by the Claimant)
Section C: Details of Industrial Disease or Accident (To be completed by the Claimant)
Note: This claim form MUST be accompanied by a completed Employer’s Certificate (Form Med.4), if you
Note: This section must be completed if you claim that your incapacity is due to an injury received or a
are currently employed. This claim WILL NOT be processed until the Form Med.4 is received. (The Form
disease contracted while working for an employer/company or due to the nature of your employment. This
Med.4 is not required for Self-Employed Persons.)
form MUST be accompanied by a completed Employer’s Report on Accident at Work (Form B.44). This claim
for industrial benefit WILL NOT be processed until the Form B.44 is received.
Mr./ Mrs./ Ms. ______________________________________________________________
6.
Last Name
First Name
Middle Name(s)
Industrial Accident
7.
N.I.# _________________________________ 8. Date of Birth _____________________________
29. Where did the accident happen? ______________________________________________________
dd/mm/yyyy
_________________________________________________________________________________
9.
House # & Street: ___________________________________________________________________
30. When did the accident happen? Date: _____________________ Time: ________ a.m. p.m.
10. Telephone #1: _________________________ 11. Telephone #2: ___________________________
dd/mm/yyyy
12. P.O. Box: _____________________
13. Email Address: _________________________________
31. State briefly how the accident happened? ______________________________________________
_________________________________________________________________________________
Employment Details
14. Occupation: ______________________________________________________________________
_________________________________________________________________________________
15. Are you Self-Employed? Yes No (If your response is ‘Yes’ then proceed to question 20)
_________________________________________________________________________________
16. Department: ___________________________ 17. Supervisor: ____________________________
32. What injury did you sustain as a result of the accident? __________________________________
18. Your Work Employee #: ___________________________
_________________________________________________________________________________
19. Employer/Company: ________________________________________________________________
_________________________________________________________________________________
20. Employer/Self-Employed N.I.#: _______________________
_________________________________________________________________________________
21. Employer/Company Address: _________________________________________________________
Employed Persons
33. Did you report the accident to your employer? Yes No
22. Telephone #1: __________________________ 23. Telephone #2: __________________________
a.m. p.m.
34. If ‘Yes’, when?
Date: ______________________
Time: ______________
24. P.O. Box: _______________________________ 25. Email Address: _________________________
dd/mm/yyyy
26. Employment History:
Self-Employed Persons
Yes No
Previous Employer/Company Name
Start Date (dd/mm/yyyy)
End Date (dd/mm/yyyy)
35. Did you report the accident to the National Insurance Board?
a.m. p.m.
36. If ‘Yes’, when?
Date: _____________________
Time: ____________
dd/mm/yyyy
Industrial Disease
37. What is the nature of your work which has caused the disease? ____________________________
_________________________________________________________________________________
27. If you were on vacation during the illness period, please state when: ____________ to ___________ .
dd/mm/yyyy
dd/mm/yyyy
_________________________________________________________________________________
28. If unemployed during the illness period, please state date employment ceased: ________________
_________________________________________________________________________________
dd/mm/yyyy
.
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