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SICKNESS Claim Checklist

  • Claim Form – N.I. 15. This form is completed where the insured has been ill for NOT less than four (4) days AND has suffered loss of earnings due to the illness.
  • Claim Form – N.I. 15A. This form is completed once the illness continues for more than fourteen (14) days.
  • ALL fields 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.

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 payslip (older than three (3) months prior to the start of the illness) / Job letter (not older than three (3) months prior to the start of the illness) / TD4 (year prior to the year of illness).
  • 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 Postala 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 MUSTbe presented.
  • The claim MUST be submitted within three (3) months from the start date of the illness, if not a letter MUST be written with an explanation for the late submission.