Industrial Injury Benefit - Claim Pack.
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- Abigayle Miles
- 8 years ago
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1 (form 01 of 04). This is form 01 of 04. Please read through this page carefully, and complete the section below. IMPORTANT - PLEASE NOTE: YOU MUST KEEP THIS PAGE. To qualify for Industrial Benefit, a member must have paid at least 52 weeks contributions before the date of the accident. When a member has been off work with an Industrial Injury for a period of eight days, the member will be entitled to five days benefit. The member will also be entitled to pay for all subsequent odd days linked with the five days. Industrial Injury Benefit will not be paid for holidays. When a member has received six weeks Industrial Injury Benefit, the member's benefit must cease until the member has commenced work and made 30 weekly full contributions when the member will be free to claim benefit for any subsequent Industrial Injury/Disease. All preceding benefits shall count in reckoning the prescribed number of weeks during which members can receive benefit unless they have been clear of benefits for a period of 30 weeks and made 30 weekly full contributions. This benefit will only be paid to members who have notified Unity of the relevant accident by completing a Unity Accident Form and returned the Accident Confirmation Form signed by the responsible person stating the accident has been properly recorded in the Accident Book. No benefit will be paid for any time lost that has not occured within 3 years of the actual date on which the accident happened, unless the member has already started to receive injury benefit for the accident prior to the end of the 3 year period. For accidents that occur before 19th May 2006: Benefits will be: ADULTS per week (for 8 weeks) per week (for 4 weeks) JUVENILES 7.50 per week (for 8 weeks) per week (for 4 weeks) For accidents that occur after 19th May 2006: Benefits will be: ALL MEMBERS per week (for 6 weeks) WHEN ALL PAGES OF THESE FORMS ARE COMPLETED AND YOU HAVE DATED THE FINAL PAGE, PLEASE RECORD BELOW THE DATE THAT YOU SEND THE FORMS BACK TO UNITY. You will normally hear from us within 14 days of receipt of these forms. If you do not receive a letter informing you that your details are with us within this time, then please contact us by completing and returning the tear off slip below as soon as it is possible, Surname Forename (s) Company Mr/Mrs/Miss/Ms _ Please confirm receipt of my accident forms completed and sent to you on: / /
2 (form 02 of 04 - Claim for Injury Benefit). THIS IS FORM 02 OF 04 - CLAIM FOR INJURY BENEFIT. PLEASE READ THROUGH THIS PAGE CAREFULLY, AND COMPLETE THE SECTION BELOW. SURNAME: (Mr/Mrs/Miss/Ms) FORENAME (S): ADDRESS: TELEPHONE No: ( ) FACTORY: CLOCK NUMBER: DATE OF INJURY: / / SIGNED: FOR HEAD OFFICE USE ONLY. Claim checked by:. Date: / / No payment can be made until membership has been verified by Head Office. Membership Number:. Geoff Bagnall - General Secretary
3 (form 03 of 04). THIS IS FORM 03 OF 04 - CLAIM FOR INJURY BENEFIT. THIS FORM IS TO BE COMPLETED BY THE HEAD OF YOUR DEPARTMENT FACTORY: NATURE OF INJURY: PLEASE COMPLETE ONE OF THE FOLLOWING SECTIONS PLEASE USE BLOCK CAPITALS I CONFIRM THERE IS AN ENTRY IN THE WORKS ACCIDENT BOOK. DATED: / / RECORDING THE FACT THAT IS ENTERED AS REPORTING AN INJURY ON / / POSITION: PLEASE USE BLOCK CAPITALS I AM UNABLE TO CONFIRM AN ENTRY IN THE WORKS ACCIDENT BOOK IN RELATION TO: NAME: FOR THE REASON OUTLINED BELOW POSITION: SIGNED: Date: / / N.B: THIS FORM IS TO RETURNED TO HEAD OFFICE BY THE CLAIMANT.
4 (form 04 of 04). THIS IS FORM 04 OF 04 - CLAIM FOR INJURY BENEFIT. PLEASE READ THROUGH THIS PAGE CAREFULLY, AND COMPLETE THE SECTIONS BELOW. ACCIDENT PARTICULARS FORM - PART ONE. Surname Mr/Mrs/Miss/Ms Nature of injuries Forename (s) Have you reported the injury to your employer? YES/NO Their Name and Posititon National Insurance Number: Date Of Birth: Is the injury recorded in the Accident Book? YES/NO If No, is it recorded elsewhere? Average Weekly Wage: Gross Area where the accident occured Take Home Names and es of any witnesses Telephone Numbers: Home Mobile Company Onset date of injury/disease, or date of accident Date Time Date you ceased work Date Time Occupation How long have you worked there? Years: Months: Sick Notes started from Have you started back to work? YES/NO If YES, when Are you doing the same job? YES/NO If No, please state below your job? Copies of Sick Notes / Medical Certificates covering the relevant period MUST be forwarded to Unity Head Office to establish entitlement to Industrial Injury Benefit. At the same rate of pay? YES/NO If No, please state your new rate of pay
5 (form 04 of 04). THIS IS FORM 04 OF 04 - CLAIM FOR INJURY BENEFIT. PLEASE READ THROUGH THIS PAGE CAREFULLY, AND COMPLETE THE SECTIONS BELOW. ACCIDENT PARTICULARS FORM - PART TWO. Name of your own Doctor Name/ of Hospital (if treated) Name of Doctor or Surgeon In the box below please explain how the accident happened: PLEASE CAREFULLY READ A & B BELOW, AND SIGN AND DATE THE APPROPRIATE BOX: A) I CONSIDER that my injury / disease during the course of my employment was due to negligence, and I request help from the Union's Solicitors in pursuing a claim for compensation. SIGNED: Date: / / B) I DO NOT CONSIDER that my injury / disease during the course of my employment was due to negligence, and no not wish to attribute blame for my injury / disease. SIGNED: Date: / / PLEASE RE-READ ALL FIVE PAGES (FOUR FORMS) THAT YOU HAVE COMPLETED, AND MAKE SURE THAT THEY ARE CORRECT. SEND THE COMPLETED FORMS AND ANY OTHER RELEVANT DOCUMENTATION TO THE ADDRESS STATED BELOW.
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