The National Insurance Board of Trinidad and Tobago

F-IOP-NI12
Maternity Benefit Application
FOR OFFICIAL USE
Local Office No.
INSTRUCTIONS
1. Please complete in CAPITAL letters.
2. Please complete in black or blue ink. The use of correction fluid is prohibited Claim No.
3. The Application must be submitted within three (3) months of the date of Delivery.

SECTION "A" - TO BE COMPLETED BY APPLICANT

1. Name:
Surname Other Name(s)
2. Home
Address:
Street

City/District/County
3. *Postal
Address (if
different from Street
above):
City/District/County
4. Valid Identification Document: (Tick appropriate box) (Present original and copy of ID)
Electoral Identification Card Passport Driver's Permit Number:

5. National Insurance No: 6. Date of Birth :

y y y y m m d d
7. Email address :

8. Was Evidence of Date of Birth Previously Submitted? YES NO

If "No", submit Birth Certificate, Passport or Affidavit with this application.

9. Telephone No.:
(Home) (Office/Work) (Cellular)
10. Have You Changed Your Name or Marital Status Since Registration?: YES NO
If "Yes", submit Marriage Certificate or Deed Poll.

11. Occupation:

12. Business Name

of Employer:
13. *Employer's
Address:
Street

City/District/County
14. Name of Actual Place of Work:
(e.g. School/Department/Division)

15. Address of Actual Place of Work:

Street

City/District/County
16. Are You Currently Employed Elsewhere?: YES NO
If "YES", state Business Name and Address of other employer.
Business Name of Employer:

Employer's Address :
Street

City/District/County

*EXAMPLE: Light Pole No. 8, Southern Main Road, Couva or Near Bertie's Parlour, Industry Lane, Belmont 02/2018
 2/F-IOP-NI12
SECTION "A" - TO BE COMPLETED BY APPLICANT (Cont'd)
17. Last Date Worked: Period of Absence: TO
y y y y m m d d y y y y m m d d y y y y m m d d
18. Please Indicate The Method of Payment of Benefit:
Mail To: Postal Address Deposit To: Financial Institution

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.

Name of Financial Institution:

Address of Financial
Institution:
Street

City/District/County
Account Number:

National Insurance (Benefits) Regulation 23 states an insured person shall be disqualified from receiving maternity benefit,
if during the period when such benefit is payable she engages in any work for which remuneration is or would ordinarily
be payable.
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.

I hereby give permission to The National Insurance Board of Trinidad & Tobago to update my registration information from
this form.

Date :
Signature of Claimant y y y y m m d d

APPLICATION SUBMITTED BY THIRD PARTY (Person other than Claimant)

I hereby authorize
Claimant's Surname Claimant's Other Name(s)
to submit this claim
Surname Other Name(s)
on my behalf.

Third Party must present a valid form of National Identification and provide contact information in order to submit claim (Present
original and copy of ID)
Valid Identification Document: (Tick appropriate box)
Electoral Identification Card Passport Driver's Permit Number:

Telephone No.:
(Home) (Office/Work) (Cellular)

Relationship to Claimant:

Date :
Signature of Claimant y y y y m m d d

Date :
Signature of Third Party
y y y y m m d d
02/2018
3/F-IOP-NI12

PARTICULARS OF WITNESS TO MARK (Where Claimant/Third Party Cannot Sign)

Name:
Surname Other Name(s)

Address:
Street

City/District/County
Occupation:

Valid Identification Document: (Tick appropriate box)

Electoral Identification Card Passport Driver's Permit Number:

Date :
Signature of Witness to Mark y y y y m m d d

SECTION "B" - TO BE COMPLETED BY A REGISTERED MEDICAL PRACTITIONER OR MIDWIFE

CERTIFICATE OF EXPECTED/ACTUAL DELIVERY

To be completed not earlier than the 11th week prior to the expected date of delivery.

I hereby certify that Miss/Mrs.

Surname Other Name(s)

was examined by me on Expected/Actual date of delivery is/was

y y y y m m d d y y y y m m d d
Is Pregnancy at least 26 weeks old at the Date of Examination? Yes No
OR
Did Delivery result in the birth of a living child or children Yes No
If "Yes"

(i) State number of children ______________________________

Words and Figures
Name of Medical
Practitioner/Midwife:
Surname Other Name(s)
Office Address of Medical
Practitioner/Midwife:
Street

City/District/County
Registration Number
of Medical Practitioner/ Telephone No.:
Midwife:

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.

STAMP Date :
Signature of Medical Practitioner/Midwife y y y y m m d d

02/2018
 4/F-IOP-NI12
INSTRUCTIONS FOR COMPLETION OF QUESTIONS 4(a) TO 6

(i) (a) In completing Question 4(a) refer to expected/actual date of delivery in SECTION "B".

(b) Check 6 weeks before the expected/actual week of delivery and enter date at 4 (b).

(c) Complete item 5, Table IA, colums (a), (b), (c) for the 13 weeks period prior to the week established at 4 (b).

(ii) In completing Table IA determine weekly earnings as follows:

(a) Where pay frequency is monthly: Monthly Earnings x 3 e.g. $800 x 3 = $184.62 (weekly) OR;
13 13

(b) Where pay frequency is fortnightly: Fortnightly Earnings e.g. $200 = $100.00 (weekly)
2 2

SECTION "C" - TO BE COMPLETED BY EMPLOYER

1. Employer's Name:

Registration No.: Telephone No.:

*2. This is to certify that Miss/Mrs

Surname Other Name(s)

has been absent from work effective TO on maternity leave.

y y y y m m d d y y y y m m d d
*Please refer to Table of Absence, IB, at question (6).
Date of Separation
3. Applicant is still employed no longer employed
y y y y m m d d

If "No Longer Employed" state reason(s).

4. (a) Expected Week of delivery begins Monday: TABLE IA

5. WEEKLY RATE OF PAY
State Weekly Rates of Pay for the 13
y y y y m m d d
week period BEFORE the week as
(b) Sixth week before expected date of delivery begins Monday: calculated at 4(b) in section C.
(a) (b) (c)
WK Date Actual Earnings
y y y y m m d d NO.
yyyy mm dd $ ¢
1
6. TABLE IB
2
3
PERIOD OF ABSENCE
4
TYPE OF LEAVE FROM TO 5
yyyy mm dd yyyy mm dd
6
7
8
9
10
11
12
13
Total

02/2018
5/F-IOP-NI12
SECTION "C" - TO BE COMPLETED BY EMPLOYER (Cont'd)

EMPLOYER'S 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.

Name:
Surname Other Name(s)
Position:

COMPANY
STAMP Date :
Signature
(If any) y y y y m m d d

SECTION "D" - FOR OFFICIAL USE

APPLICATION RECEIVED BY:
Name:
Surname Other Name(s)

SERVICE CENTRE
Date :
Signature of Service Centre Staff STAMP
y y y y m m d d

PART I - CUSTOMER SERVICE REPRESENTATIVE

1. Name, N.I. No. and Date of Birth Confirmed and Updated (If Necessary) On I.A. System? Yes No

2. Registration Record Complete? (If "No" complete forms NI 165/NI 182 as applicable) Yes No

3. Check for Duplicate Registration (SIRF file included)? (Record Result on Minute Sheet Yes No
4. Claim History Viewed?
Yes No
(If yes, record findings here.)
(Use minute sheet if this space
is inadequate.)
5. Application Completed and Accepted for Processing? Yes No

6. Application Recorded? (Print and attach Claim Profile) Yes No

7. Contribution Recorded and Transferred? (Print and attach Audit Report) Yes No

8. Application Processed? Yes No

Date :
Customer Service Representative y y y y m m d d

02/2018