Form B-44 S/e - Self-Employed Report On Accident At Work
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1
2The National Insurance Act, 1972
Commonwealth of The Bahamas
S
-E
R
A
W
ELF
MPLOYED
EPORT ON
CCIDENT AT
ORK
Instructions for Completing This Form
1. The National Insurance Regulations require that all accidents be reported by self-employed persons.
2. The entire form is to be completed.
3. Submit the form immediately or within one (1) month of the date of accident to the nearest National Insurance
Local Office to avoid delay in the processing of the claim; failure to submit this form within the specified
timeframe may result in the imposition of penalties (fines of up to $500).
SECTION A: SELF-EMPLOYED BUSINESS INFORMATION
Business Name: ______________________________________________________________________
Self- Employed Registration No.
Street Address: _______________________________________________
P.O. Box: _____________
Tel. No.: ___________________
E-Mail: ________________________________________________
Nature of Industry of Business: __________________________________________________________
State last date of contributions: ______ / ______ / _______ Month & Year paid for: _______ /________
mm
yyyy
dd
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yyyy
SECTION B: INJURED PERSON’S INFORMATION
Name: _________________________________________
N.I. No.
Street Address: _______________________________________________
P.O. Box: _____________
Tel No.: _____________________ (h)
______________________(w) _____________________ (c)
E-Mail: ______________________________________________________
Occupation: __________________________________________________
What are your duties: _________________________________________________________________
Date of Accident: ______ / ______ / ________ Time: __________ a.m./p.m.
dd
mm
yyyy
Place of Accident: ____________________________________________________________________
Description of apparent Injury/incapacity: _________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
What hours were you expected to work that day? From______a.m./p.m. to:______ a.m./p.m.
SECTION C: REPORT OF ACCIDENT
1. When was the accident first reported to NIB? : ______ / ______ / ________ Time: ________a.m./p.m.
dd
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yyyy
2. If the accident was not reported on the day it happened, state why:
_______________________________________________________________________________
_______________________________________________________________________________
Form B-44 S/E [revised 11/2011]
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