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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 | ||
|---|---|---|---|
 |
Authorization to Pay a representative |
Form to be submitted when sending someone to collect a payment from NIB on your behalf. | 08.22.19 |
|
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. | 02.12.2020 |
|
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 |
|
B82 Unemployment |
Claim For Unemployment Benefit | 03.26.2020 |
|
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 |
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