THE NATIONAL INSURANCE BOARD NI 15A CONTINUATION …

1 THE NATIONAL INSURANCE BOARD CONTINUATION claim TO sickness BENEFITNI 15A(PLEASE USE CAPITAL LETTERS)I hereby certify that Mr/Mrs/Misswas examined by me on and in my opinion was at the time suffering fromIn my opinion this patient will remain incapable of work for a period ofdays starting from words and figuresNATIONAL INSURANCE OR MARK OF CLAIMANT DATE:Y Y Y YM MD DI. hereby consent to thefollow-up Medical Certificate at Section "B" being submitted to the NATIONAL INSURANCE : Subsequent medical certificates must be submitted no later than three (3) months from the last date of incapacity on the previous medical certificate.

2 SECTION "A" - PARTICULARS OF APPLICANTSURNAME OTHER NAME(S) SURNAME OTHER NAME(S) Y Y Y YM MD DY Y Y YM MD D07/2009I declare that to the best of my knowledge and belief the information given by me is true and correct and I am aware that ifthere is any statement in this declaration which is false in fact or which I know or believe to be false or do not believe tobe true, I am liable on summary conviction to a fine of three thousand dollars ($3, ) and to imprisonment for twoyears in accordance with Sect 33, NI Act Chap 32:01. (FOR OFFICIAL USE)SERVICE CENTRE CODE: claim NO:SIGNATURE OF WITNESS TO MARK DATE:MMDDYYYYPARTICULARS OF WITNESS TO MARK (Where Claimant Cannot Sign)ADDRESS:(STREET)(CITY/DISTRICT/COUN TY) NAME:SURNAMEOTHER NAME(S)OCCUPATION:VALID IDENTIFICATION: (Tick appropriate box)NUMBER:PASSPORTDRIVER'S PERMITELECTORAL has been sent to the BOARD 's Medical Adviser?

3 YESNOSECTION "B" - TO BE COMPLETED BY MEDICAL PRACTITIONERSUBSEQUENT MEDICAL CERTIFICATES ickness is/ is not as a result of an accident on the OF SEPARATION:Y Y Y YM MD DIf "NO LONGER EMPLOYED", state reason(s) 15A SECTION "C" - TO BE COMPLETED BY EMPLOYERA pplicant is still employed no longer FOR COMPLETIONThis Section must be completed by the Employer before the Application is submitted to the BOARD .(i)In completing Column 4(d) below proceed as follows:(ii)Weekly Earnings =Monthly Earnings x 3 ( $ x 3 = $ ) OR 13 13(b)Weekly Earnings =Fortnightly Earnings ( $ =$ ) 2 2(c)Daily Earnings =Weekly Earnings ( $ = $ ) 7 7(d) 'S NAME:TELEPHONE NO:REGISTRATION NO.

4 This is to certify that during the period recorded at Section "B" of this form Mr/ NAME(S) has been absent from -07/2009 SECTION "B" - TO BE COMPLETED BY MEDICAL PRACTITIONER (Cont'd)NOTE:In the case of a FIRST or SECOND CERTIFICATE the period of certified incapacity must not exceed 14 DAYS including Sundaysand Public Holidays. In the case of a THIRD OR SUBSEQUENT CERTIFICATE THE PERIOD entered must not exceed 28 DAYS including Sundays and Public OF MEDICAL PRACTITIONER: OFFICE ADDRESS:MEDICAL PRACTITIONER'S STAMP SIGNATURE OF MEDICAL PRACTITIONERI 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 thereis 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 amliable on summary conviction to a fine of three thousand dollars ($3, ) and to imprisonment for two years in accordancewith Sect 33, NI Act Chap 32.

5 (CITY/DISTRICT/COUNTY)(STREET)SURNAMEOTH ER NAME(S)MMDDYYYYTELEPHONE NUMBER:--REGISTRATION NUMBER OFMEDICAL PRACTITIONER: (a) Earnings mean wages or salary and include overtime payments, long service payments, commissions, payment for standby duty, allallowances, etc. 3/NI 15 AWas Loss of Earnings caused by sickness ?(a) Yes (b) NoIf "No", please state reason for Loss of Earnings: 5. SECTION "C" - TO BE COMPLETED BY EMPLOYER (Cont'd) 1 2 3 4 5(d) DAILY EARNINGSDURINGSICKNESSDAILY EARNINGS DURING sickness (a)NO.(b)PERIOD OF ABSENCE YYYY MM DDYYYY MM DD(c)TOTAL NO. OFDAYS$cFROM TO07 'S DECLARATIONPOSITION:COMPANYSTAMP (If any)DATE: YYYYMMDDSIGNATURE OF EMPLOYERI declare that to the best of my knowledge and belief the information given by me is true and correct and I am aware that ifthere 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 betrue, I am liable on summary conviction to a fine of three thousand dollars ($3, ) and to imprisonment for two yearsin accordance with Sect 33, NI Act Chap 32 : SURNAMEOTHER NAME(S)SECTION "D" - FOR OFFICIAL USENAME: SIGNATURE OF CUSTOMER SERVICE REPRESENTATIVEDATE.

6 SURNAMEOTHER NAME(S)MMDDYYYYRECEIVED BY:SERVICE CENTRERECEIVED STAMP