Fillable Printable The National Insurance Board Retirement Benefit Application

The National Insurance Board Retirement Benefit Application

THE NATIONAL INSURANCE BOARD

RETIREMENT BENEFIT APPLICATION

1. NAME:

10. LAST

OCCUPATION:

15. LAST DATE OF EMPLOYMENT:

11. NAME OF

LAST EMPLOYER:

16. HAVE YOU EVER APPLIED FOR A RETIREMENT BENEFIT?

If "YES", state Service Centre:

*EXAMPLE: Light Pole No. 8, Southern Main Road, Couva OR Near Bertie's Parlour, Industry Lane, Belmont.

SECTION "A" - TO BE COMPLETED BY APPLICANT

NI 82

MM DDYYYY

SURNAME OTHER NAME(S)

(STREET)

(CITY/DISTRICT/COUNTY)

8. MARITAL STATUS:

SINGLE MARRIED WIDOWED DIVORCED

9. STATE MAIDEN NAME

(Where applicable):

SURNAME

12. LAST EMPLOYER

REGISTRATION NO:

(If known)

13. EMPLOYMENT RECORD FROM 10 APRIL, 1972.

NAME OF EMPLOYER ADDRESS OF EMPLOYER PERIOD OF

EMPLOYMENT

N.B. This should include pre-retirement leave/vacation leave. (See pg. 4 for details)

(PLEASE USE BLOCK/CAPITALS)

(Please use additional sheets of paper if more space is required.)

TYPE OF EMPLOYMENT

TEMPORARY/CASUAL/

PERMANENT

14. DID YOU WORK OR LIVE IN CANADA OR WORKED IN ANY OF THE CARICOM COUNTRIES?

If "YES", please provide:

(i) SOCIAL SECURITY NO.

(ii) COUNTRY:

NOTE: This application must be submitted not later than 12 months from the date of Retirement.

YES NO

2. HOME

ADDRESS:

3. *POSTAL

ADDRESS (if

different

from above):

(STREET)

(CITY/DISTRICT/COUNTY)

08/2011

(FOR OFFICIAL USE)

SERVICE CENTRE CODE:

CLAIM NO:

Please read the notes at the back of this form CAREFULLY.

YES NO

MALE

FEMALE

6. GENDER:

5. DATE OF

BIRTH:

MM DDYYYY

4. NATIONAL

INSURANCE NO.:

7. TELEPHONE NUMBERS:

-- --

(HOME) (OFFICE/WORK) (CELLULAR)

2/NI 82

17. ARE YOU IN RECEIPT OF ANY BENEFIT LISTED BELOW?

(a) INVALIDITY

(b) SICKNESS

18. HAVE YOU PAID VOLUNTARY CONTRIBUTIONS?

20. IS THIS ACCOUNT A JOINT ACCOUNT?

YES NO

SECTION "A" - TO BE COMPLETED BY APPLICANT (CONT'D)

21. IF "YES", PLEASE STATE THE NAME(S) AND ADDRESSES OF JOINT ACCOUNT HOLDER(S).

NAME:

SURNAME

OTHER NAME(S)

ADDRESS:

(STREET)

(CITY/DISTRICT/COUNTY)

NAME:

SURNAME

OTHER NAME(S)

ADDRESS:

(STREET)

(CITY/DISTRICT/COUNTY)

YES NO

08/2011

ACCOUNT NUMBER:

ADDRESS:

NAME OF FINANCIAL

INSTITUTION:

(STREET)

(CITY/DISTRICT/COUNTY)

19. PLEASE INDICATE THE METHOD OF PAYMENT OF BENEFIT:

MAIL TO:

POSTAL ADDRESS

DEPOSIT TO:

FINANCIAL INSTITUTION

(If method of payment is "FINANCIAL INSTITUTION", complete below).

FINANCIAL INFORMATION

(If method of payment is "FINANCIAL INSTITUTION", complete below).

The NIBTT considers the foregoing information as instructions from you regarding the deposit of your benefit payment to the

financial institution of your choice.

The NIBTT is not liable for any payment issued to an inaccurate financial institution or account based on these instructions.

SIGNATURE OR MARK OF APPLICANT

DATE:

SIGNATURE OF WITNESS

DATE:

MM DDYYYY

PARTICULARS OF WITNESS TO MARK (Where Claimant Cannot Sign)

ADDRESS:

(STREET)

(CITY/DISTRICT/COUNTY)

NAME:

SURNAME

OTHER NAME(S)

OCCUPATION:

VALID IDENTIFICATION:

(Tick appropriate box)

NUMBER:

PASSPORT

DRIVER'S PERMIT

ELECTORAL I.D.

MM DDYYYY

DECLARATION

I declare that to the best of my knowledge and belief the information given by me is true and correct and I am aware that if

there is any statement in this declaration which is false in fact or which I know or believe to be false or do not believe to be

true, I am liable on summary conviction to a fine of three thousand dollars ($3,000.00) and to imprisonment for two years

in accordance with Sect 33, NI Act Chap 32:01.

COMPANY

STAMP

(If any)

NAME:

SURNAME

OTHER NAME(S)

POSITION:

SIGNATURE:

DATE:

MM DDYYYY

I certify that

SURNAME

OTHER NAME(S)

whose date of birth is retired from our Employment with effect from

MM DDYYYY

HAS BEEN RE-EMPLOYED WITH EFFECT FROM

HAS NOT BEEN RE-EMPLOYED AFTER

TICK APPROPRIATE BOX:

MM DDYYYY

I declare that to the best of my knowledge and belief the information given by me is true and correct and I am aware that if

there is any statement in this declaration which is false in fact or which I know or believe to be false or do not believe to be

true, I am liable on summary conviction to a fine of three thousand dollars ($3,000.00) and to imprisonment for two years

in accordance with Sect 33, NI Act Chap 32:01.

SECTION "B" - TO BE COMPLETED BY LAST EMPLOYER (SEE NOTE NO. 8 ON PAGE 5)

3/NI 82

08/2011

4/NI 82

2. REGISTRATION RECORD COMPLETED?

PART "I" - CUSTOMER SERVICE REPRESENTATIVE

6. APPLICATION RECORDED? (Print and attach Claim Profile)

SECTION "C" - FOR OFFICIAL USE

7. OUTSTANDING CONTRIBUTION RECORDED? (Print and attach Audit Report)

CUSTOMER SERVICE REPRESENTATIVE

5. APPLICATION COMPLETED AND ACCEPTED FOR PROCESSING?

DATE:

1. NAME, N.I. NO. AND DATE OF BIRTH CONFIRMED AND UPDATED (IF NECESSARY) ON I.A. SYSTEM

3. CHECK FOR DUPLICATE REGISTRATION (SIRF file included)? (Record Results on Minute Sheet)

8. APPLICATION PROCESSED?

(If "NO" complete forms NI 165/NI 182 as applicable)

MM DDYYYY

4. CLAIM HISTORY VIEWED?

(If yes, record findings here.)

(Use minute sheet if this

space is inadequate.)

YES NO

NAME:

SIGNATURE OF SERVICE CENTRE STAFF

DATE:

SURNAME OTHER NAME(S)

MM DDYYYY

APPLICATION RECEIVED BY:

SERVICE

CENTRE

STAMP

08/2011

PART II - MANAGER/SUPERVISOR/CLERICAL OFFICER II

1. DETAILS OF CLAIM PROFILE VERIFIED?

3. CONTRIBUTIONS TRANSFERRED?

2. CONTRIBUTION AUDIT REPORT VERIFIED?

MM DDYYYY

MANAGER/SUPERVISOR/CLERICAL OFFICER II

4. CLAIM AUTHORIZED/DISALLOWED?

DATE:

YES NO

5/NI 82

2. Retirement Benefit is payable from age 60 (provided that you are no longer in Insurable Employment)

OR from age 65 whether employed or not. Your application must be submitted not later than 12

months from the Date of Retirement.

1. Use BLOCK/CAPITALS to complete this Form.

RETURN OF BENEFIT APPLICATION

3. There are TWO types of Retirement Benefit:

(a) Retirement Pension, OR (b) Retirement Grant, if you do not qualify for the Pension.

Leaflets available at your Service Centre will provide details on these Benefits.

6. Your completed Form MUST be accompanied by a CERTIFIED COPY of your Birth

Certificate/Affidavit if necessary. In the case of a married Female, a CERTIFIED COPY of your

Marriage Certificate MUST ALSO be submitted.

7. Your Retirement Pension Payments will be sent to a Financial Institution of your choice every month.

Note however, a Form NI 65 - "Life Certificate" MUST be completed and submitted as required by the

Board for payments to continue. These certificates are available from any Service Centre.

5. For item 18, Voluntary Contributions are paid by an insured person who is unemployed and wishes to

maintain his contribution record during periods of unemployment.

4. For item 15, the "Last Date Of Employment", relates to the last date on which you were paid by your

Employer.

8. SECTION 'B' is to be completed by last employer for persons who were no longer in insurable

employment prior to age 65.

08/2011