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SPECIAL MATERNITY Claim Checklist


Claim Form – N.I. 13. This form is completed where the insured has delivered a child. If the applicant is entitled to the Maternity benefit, complete N.I. 12.

  • 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.

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.
  • This section MUST NOT be completed prior to delivery.

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.
  • Original & Copy of the child's Birth Certificate where Section "B" was completed by a MIDWIFE.
  • Original & Copy of payslip (older than three (3) months prior to the date of delivery) / Job letter (not older than three (3) months prior to the date of delivery) / TD4 (year prior to the year of delivery).
  • 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 three (3) months from date of delivery, if not a letter MUST be written with an explanation for the late submission.