Employer Request For Access To The Online C10 System Form printable pdf download

The National Insurance Board

Employer

Request for Access to

The Online C10 System

Name of Business: ________________________________________________________

Employer NI#:

_________________ Industry________________________________

(To be completed if business is sole proprietorship)

Self-Employed NI#:_____________S/E Name:__________________________________

Business Address: ________________________________________________________

Descriptive Address:_______________________________________________________

________________________________________________________________________

P. O. Box: _____ _______________City/Settlement:____________________________

Island.: _______________________________Business License #: __________________

Phone 1:

______________ Extn.: ___________Phone 2: ______________________

Fax Number: ______________________Cell Phone: ____________________________

Contact Person:

________________________Position__________________________

Email Address:

________________________________________________________

Alt. Email Address:_______________________________________________________

Preferred Method of Communication with NIB:

Fax

Regular Mail

Terms of Access

1. Access to the National Insurance Board’s website has been granted to the above referenced

business for the sole purpose of entry and submission of online C10s.

2. All user-ids and passwords assigned are expected to be kept confidential by the indicated Contact

Person. You are required to immediately advise N.I.B. of any change in Contact Person.

3. Submission of data through this service is accepted as having been officially presented to The

National Insurance Board as a signed document.

4. The National Insurance Board reserves the right to terminate the assigned access at its sole

discretion at any time.

I agree to the terms detailed above.

Signed:

___________________________

Date: _____________________

Print Name:____________________________

Position:___________________

To expedite processing, the completed application may be scanned and e-mailed to .

Please note that before access is granted, the original document must have been received at NIB’s Inspectorate

Department, P. O. Box N 7508, Nassau, Bahamas or it may be hand-delivered to your nearest NIB office.

Employer Request For Access To The Online C10 System Form