The National Insurance Act, 1972 (To be completed …

1 MEDICAL CERTIFICATE OF INCAPACITY FOR WORKS ection A:To be completed by a Registered Medical Confidence to: Mr. / Mrs. / certify that I examined you on _____ and that in my opinion, you were incapable ofworking at the time of the / Operation:ICD-9 CodeDescription of will remain incapable of work from _____ to _____(Note: The period entered must NOT exceed 13 weeks) :_____Date:_____dd/mm/yyyyLast NameFirst NameMiddle Name(s)dd/mm/yyyydd/mm/yyyyName (printed)SignatureAffix Doctor sStamp hereNote: Claims from Registered MedicalPractitioners outside The Bahamas MUST beaccompanied by a business Med 1 The National Insurance Act, 1972 Commonwealth of The BahamasFor Official Use OnlySection D: Claimant s Declaration (To be completed by the Claimant)I declare that:38.

2 My last day at work was I am incapable of work and have done no paid work since the date shown at question The information given by me on this form is true and correct to the best of my knowledge and I claim Benefit/Assistance under the National Insurance Act, Claimant s Signature: _____OR, if unable to sign,Agent/Representative s _____Date: _____IMPORTANT NOTE: Any person who for the purpose of obtaining benefit under The National InsuranceAct, for himself or for some other person, knowingly makes any false statement or false representationsor produces any document, etc.

3 Which he knows to be false, shall be liable to a fine not exceeding TwoThousand Five Hundred Dollars ($2,500), or to imprisonment for a period not exceeding twelve (12)months or Official Use OnlyForm Med 1 (Revised 2012)Name (printed)Signaturedd/mm/yyyydd/mm/yyyySe ction B: Claimant Details (To be completed by the Claimant)Note: This claim form MUST be accompanied by a completed Employer s Certificate (Form ), if youare currently employed. This claim WILL NOT be processed until the Form is received. (The is not required for Self-Employed Persons.)

4 6. Ms. #_____8. Date of Birth # & Street: _____10. Telephone #1:_____ 11. Telephone #2: _____12. Box: _____13. Email Address: _____Employment Details14. Occupation:_____15. Are you Self-Employed? Yes No (If your response is Yes then proceed to question 20)16. Department:_____ 17. Supervisor:_____18. Your Work Employee #: _____19. Employer/Company: _____20. Employer/Self-Employed #:_____21. Employer/Company Address:_____22. Telephone #1:_____ 23. Telephone #2: _____24. Box: _____ 25. Email Address: _____26.

5 Employment History:Previous Employer/Company NameStart Date (dd/mm/yyyy)End Date (dd/mm/yyyy)27. If you were on vacation during the illness period, please state when: _____ to _____ .28. If unemployed during the illness period, please state date employment ceased: NameFirst NameMiddle Name(s)dd/mm/yyyydd/mm/yyyydd/mm/yyyydd/ mm/yyyySection C: Details of Industrial Disease or Accident (To be completed by the Claimant)Note: This section must be completed if you claim that your incapacity is due to an injury received or adisease contracted while working for an employer/company or due to the nature of your employment.

6 Thisform MUST be accompanied by a completed Employer s Report on Accident at Work (Form ). This claimfor industrial benefit WILL NOT be processed until the Form is Accident29. Where did the accident happen?_____30. When did the accident happen? Date: _____Time:_____ State briefly how the accident happened?_____32. What injury did you sustain as a result of the accident?_____Employed Persons33. Did you report the accident to your employer? Yes No34. If Yes , when?Date:_____ Time: _____ Persons35. Did you report the accident to the National Insurance Board?

7 Yes No36. If Yes , when?Date: _____ Time: _____ Disease37. What is the nature of your work which has caused the disease?_____dd/mm/yyyydd/mm/yyyydd/mm/y yyy