Benefit & Assistance

These are the forms used for submission of claims Short Term Benefits, Long Term Benefits and Medicare Benefits.

Select the required form from the list.
Benefit & Assistance Update
B.44 Industrial Accident Form required for submission of claims for industrial accident/injury benefit. 03.22.2013
B.44 Self Employed Form required for submission of industrial accident for self-employed persons 03.22.2013
  B.46 Employer Contribution Request Form  Form provide the total insurable wages on which contributions have been paid or are due to be paid.  07.21.2015 
B.47 Disablement Form required for submission of claims for disablement benefit. 09.14.2009
B.51 Funeral Form required for submission of claims for funeral benefit. 09.14.2009

 		 B.58 Form - Retirement  This form needs to be completed to begin the process associated with Retirement Benefit.   05.2017
  B.58(b) Form - Retirement  All claims for Retirement Benefit made by individuals younger than 65 years must be accompanied by the Employers Retirement Confirmation (Form B58[b]). This form seeks the employer's verification that the claimant has retired from his employ, or if not retired, confirmation of the wages paid. It is to be duly completed and signed by the employer or his representative.  07.16.2019
  B.67 Beneficiary Deceased   Form required for submission of claims for Survivors Benefit or Assistance.  09.14.2009 
  B.80 Termination of Service   Lay-Off Certificate. 07.21.2015 
  Med.1 Sickness_Injury  Form required for submission of claims for sickness and injury benefits.  03.12.2013 
Med 1 - Incapacity for Work Form required for submission of claims for sickness and injury benefits when period of incapacity exceeds 26 weeks.   11.10.2016 
Med.2 Maternity  Form required for submission of claims for maternity benefit/grant for both before and after confinement.   09.14.2009 
Med.3B Maternity Grant (Spouse) Form required for submission of claims for maternity grant, where the spouse's contributions are being used.  09.14.2009 
Med.4 Employer Certificate   Form required for certification or confirmation by the employer of claimants stated period of incapacity.   09.24.2015 
B.75a Assistance Verification Form needed for twice annual verification by pensioners in receipt of long-term Assistance. 09.14.2009
B.75b Benefit Verification Form needed for twice annual verification by pensioners in receipt of long-term Benefits. 04.30.2012
B.82  Claim For Unemployment Benefit  02.01.2011
Invalidity Benefit Claim Form Invalidity Benefit Claim Form 06.22.2010
Survivors Student Confirmation  Survivors Student Confirmation amended 10.03.2011
Survivors Benefit Claim Form Survivors Benefit Claim Form amended 01.04.2011
Direct Deposit of Benefit/ Assistance to Bank Account Direct Deposit Form for direct banking 06.14.2013