Claim For Maternity Allowance And Grant Form - National Insurance Act

NATIONAL INSURANCE ACT, 1986

CLAIM FOR MATERNITY ALLOWANCE AND GRANT

* CERTIFICATE OF EXPECTED CONFINEMENT

To be completed by insured person.

To be completed by a Medical Practitioner or a Registered Midwife only.

Put your NATIONAL INSURANCE NUMBER here

To: Director, National Insurance Services

To: Mrs./Miss __________________________________________________

(Full Name)

I ___________________________________________________________

I certify that I have examined you today and that in my opinion you are pregnant

(Full name in block capitals)

and should be confined during the week commencing:

residing at ____________________________________________________

Monday ________________________________ 20 ______

___________________________________Telephone: _________________

(Address)

hereby claim a maternity grant, and maternity allowance

Signature____________________________ (

Medical Practitioner/Registered Midwife)

from _____________________________

Address_____________________________

Date___________________

to _______________________________ (period from which Allowance is claimed)

I attach a

* Certificate of Expected Confinement/

* Certificate of Confinement signed by _____________________

* CERTIFICATE OF CONFINEMENT

I am/was last employed by ______________________________________

To be completed by a Medical Practitioner or a Registered Midwife only.

____________________________________________________________

(Name and Address of Employer)

To: Mrs./Miss ___________________________________________________

and stopped *

(Full Name)

___________ work on _______________________________________

(Date)

intend to stop*

I cerfity that I attended you at your confinement which took place on ____________

(If you have worked for any other employers during the last 30 weeks, please list

their names and addresses on the back of this form.)

___________________ resulting in the live/still birth of ________ child/children.

(Date)

(Number)

I do not intend to work during the period for which I have claimed benefit.

I hereby declare that the information given above is true to the best of my knowledge

Signature ____________________________ (

Medical Practitioner/Registered Midwife)

and belief and I will NOT received maternity allowance for any period during which

I was at work.

Date _______________________________

My Bank Account/Credit Union number is ___________________________

* Complete whichever is appropriate.

at _______________________________________________________

IMPORTANT

Please complete form fully and send to the National Insurance Office promptly. Delay may mean loss of

Signature of Claimant _________________________________________

benefit, since benefit may not normally commence earlier than the week in which the claim is received.

(or other person authorised to sign on behalf of Claimant)

Maternity benefit is payable for a period starting from the week not earlier than six weeks before the

Date ______________________________________________________

expected date of confinement and continuing until the expiration of 13 weeks. However, benefit cannot

be paid for a period while the insured person is working and any person who receives benefit for a

period while she is at work commits an offence.

* Delete whichever is inappropriate.

WARNING: Any person who knowingly makes any false statement for the purpose of obtaining benefit

commits a criminal offence punishable by a fine or imprisonment or both.

* See important notes on right of this form.

Claim For Maternity Allowance And Grant Form - National Insurance Act - 1986

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