INJURY Claim Checklist

  • Claim Form N.I. 19. This form is completed when the insured has suffered a personal injury due to a job related incident.
  • Claim FormN.I. 19A. This form is completed once the incapacity continues for more than fourteen (14)days.
  • ALLFields must be completed. ALL changes MUST be initialed and / or stamped.

Section "A" to be completed by the insured.

  • The form MUST be signed and dated by the Insured.
  • If the insured is unable to sign, the thumbprint will be certified at the NIBTT.
  • If the claim is being submitted by a third party, at the “Particulars of Witness to Mark” the thumbprint should be certified by an approved authority.
  • The insured MUST provide clear and concise details of the incident. An original or certified copy of an accident report may be provided.

Section "B" to be completed by a Registered Medical Practitioner.

  • The form MUST be signed, dated and stamped by the Registered Medical Practitioner.
  • The Registered Medical Practitioner’s registration number MUST be correctly stated.

Section “C”to be completed by the Employer.

  • The form MUST be signed, dated and stamped by the Employer.
  • The Employer’s Registration number and contact information MUST be correctly stated.
  • If the insured is employed by more than one employer EACH employer MUST complete Section “C”.
  • Identification Card of Insured.
  • Original Copy of the Birth Certificate / Affidavit / Deed Poll where there is a change to the insured’s name.
  • If the method of payment is Financial,the bank statement reflecting the name of the bank, the account number and the branch should be submitted. If the method of payment is Postal a utility bill, no older than three (3) months should be submitted.
  • If the claim is being submitted by a third party, the Identification Card of the third party MUST be presented.
  • The claim MUST be submitted within fourteen (14) days from the start date of the incapacity, if not a letter MUST be written with an explanation for the late submission.