Social Welfare Services

Application form for OB21

Disablement Benefit and/or Incapacity

Supplement under the Occupational Injuries Scheme

How to complete application form for Disablement Benefit and/or Incapacity

Supplement under the Occupational Injuries Scheme.
• Please tear off this page and use as a guide to filling in this form.

• Please use Black ball point pen.

• Please use BLOCK LETTERS and place an X in the relevant boxes.

• Please answer all questions that apply to you. If a question does not apply to
you, please leave the answer area blank.

• You need a Personal Public Service Number (PPS No.) before you apply.

If you are applying because of an accident at work, complete Parts 1, 2, 3, 4, 7 and

have your employer fill in Part 5. When the form is complete, sign the declaration
in Part 1.
If you are applying because of a work-related disease, complete Parts 1, 2, 3, 6, 7
and have your employer fill in Part 5. When the form is complete, sign the
declaration in Part 1.
If you also want to claim Incapacity Supplement, complete Part 8 too. When the
form is complete, sign the declaration in Part 1.
If you also want to claim Constant Attendance Allowance, complete Part 9 too.
When the form is complete, sign the declaration in Part 1.

If you need any help to complete this form, please contact your local Social
Welfare Office or Citizens Information Centre.
For more information, log on to www.welfare.ie.
 How to fill in first page of this form
To help us in processing your application:
• Print letters and numbers clearly.
• Use one box for each character (letter or number).
Please see example below.
1. Your PPS No.: 1 2 3 4 5 6 7 T
2. Title: (insert an ‘X’ or Mr. Mrs. X Ms. Other
specify)
3. Surname: M U R P H Y

4. First name(s): M A U R E E N
5. Your first name as it M A R Y
appears on your birth
certificate:
6. Birth surname: M C D E R M O T T
7. Your mother’s birth K E L L Y
surname:
8. Your date of birth: 2 8 0 2 1 9 7 0
D D M M Y Y Y Y

Contact Details

9. Your address: 1 N E W S T R E E T
O L D T O W N
C O D O N E G A L

10.Your telephone number: 0 8 6 1 2 3 4 5 6 7

MOBILE
0 1 7 0 4 3 0 0 0
LANDLINE
11.Your email address: M M U R P H Y @ W E L F A R E . I E

SAMPLE
 Social Welfare Services
Application form for OB21
Disablement Benefit and/or Incapacity
Supplement under the Occupational Injuries Scheme

Part 1 Your own details

1. Your PPS No.:
2. Title: (insert an ‘X’ or Mr. Mrs. Ms. Other
specify)
3. Surname:
4. First name(s):
5. Your first name as it
appears on your birth
certificate:
6. Birth surname:
7. Your mother’s birth
surname:
8. Your date of birth:
D D M M Y Y Y Y
Contact Details
9. Your address:

10.Your telephone number: MOBILE

LANDLINE

11.Your email address:

Declaration
I declare that all the information I have given on this form is accurate. I will tell the Department when my
means or circumstances change.
I give permission to the hospital or clinic named in Part 7 to provide the Department of Social and Family
Affairs with any relevant medical information about my treatment.
If you cannot sign your name, make a mark, such as an X, and have a witness sign their name beside it.
Date: 2 0
D D M M Y Y Y Y
Signature (not block letters)
Warning: If you make a false statement or withhold information, you may be
prosecuted leading to a fine, a prison term or both.
Part 1 continued Your own details
12.What is your old Social
Insurance number, if any?
Single Widowed Remarried Divorced
13.Are you?
Married Cohabiting Separated
14.What country were you
born in?
15.What was your job when
the accident/disease
occurred?
16.Are you getting or have you claimed any payments from this Department or from any other
EU country? Yes No
If ‘Yes’, please state:
Type of payment:
Your claim or reference
number:
Name of country that pays
you:
17.Are you applying for this payment within 3 months of the date of the accident?
Yes No

If ‘No’, do you wish to have your claim backdated?

Yes No

If ‘Yes’, give reason(s) for

not applying sooner:

Failure to claim within 3 months of the start of your disablement

may result in loss of benefit.
Part 2 Your payment details

Disablement Benefit is paid directly to your current or deposit savings account in a

financial institution.

Financial Institution
You will get the following details printed on statements from your
financial institution.

Name of financial institution:

Sort code:

Account number:

Bank Identifier Code (BIC):

International Bank Account

Number (IBAN):

Name(s) of account holder(s):

Name 1:

Name 2 (if any):

If you do not have an account in a financial institution please contact Disablement

Benefit Section.
Part 3 Details of your disablement
a work-related accident?
18.Have you suffered a loss
of faculty because of...?
a work-related disease?

19.Are you incapable of work because of the accident or disease?

Yes No

20.Are you fit to travel for a medical exam?

Yes No

21.Did you receive Injury Benefit for this accident or disease?

Yes No

22.Who were you working for at the time of the accident or disease?
Employer’s name:

Employer’s address:

Employer’s telephone
number:
MOBILE

LANDLINE

Your Employer’s Registered

Number:

Dates you worked From:

there:
To:
D D M M Y Y Y Y

If your employment was hours a week

part-time how many hours a
week did you work?
Part 4 Details of accident at work
23.Please state:
- Date of accident:
D D M M Y Y Y Y
- Time: . am/pm

- Place of accident:
24.Have you reported the accident to your employer?
Yes No
• If ‘No’, you should report it immediately.
25.What were you doing at
the time of the accident
and how did it happen?

26.What injuries did you

receive?

27.Give names and addresses of any witnesses to the accident:

Their surname:

Their first name:

Their Address:

Their surname:

Their first name:

Their Address:

Their surname:

Their first name:

Their Address:
Part 5 Employer’s account of accident
28.Please state:
- Date employment started:
D D M M Y Y Y Y
- What class PRSI
contributions were paid?

- Was employment part- Yes No

time?
- If ‘Yes’, please state number hours a week
of hours a week:

29.I agree with the date, time and place of accident and injuries received by the applicant:
Yes No

Did the accident happen during normal working hours?

Yes No

Was the applicant doing something permitted for the purpose of their work?
Yes No

If ‘No’, give details here:

Did they work on any day(s) after the date of the accident?
Yes No

If 'Yes' when did they work,

and for how long?

Has the applicant returned to work since the accident?

Yes No

If ‘Yes’, give date here:

D D M M Y Y Y Y
Part 5 Employer’s account of accident

Employer’s name:

Position in company:

Employer’s telephone
number:
MOBILE

LANDLINE

Employer’s email address:

Employer’s official stamp

Signature (not block letters)

Date: 2 0
D D M M Y Y Y Y
Part 6 Details of work-related disease
Please read information booklet SW 33 for full details of diseases covered by Disablement
Benefit.
30.Please give name of
disease you contracted at
work:
31.What type of work do you
think caused the disease?
How long have you been doing this type of work?
years months

On what date did you last

do this type of work?
D D M M Y Y Y Y

On what date did you

develop the disease?
D D M M Y Y Y Y

32.Have you claimed benefit before now for the disease from this Department or from another
EU country? Yes No

If ‘Yes’ please state:

Date you claimed:
D D M M Y Y Y Y

Your Claim or reference

number:

Name of country you

applied to for benefit:
Part 7 Your medical details
33.Please give details of your doctor:
Doctor’s surname:

Doctor’s first name:

Doctor’s address:

34.Did you receive medical attention for the injury/disease at a hospital or clinic?
Yes No

If ‘Yes’, please state:

Name of hospital or clinic:
Address of hospital or
clinic:

Name of consultant or
specialist:

Period of From:
treatment:
To:
D D M M Y Y Y Y

Did you stay overnight? Yes No

Did you have an Yes No

operation?
 application for Incapacity Supplement

If you wish to claim Incapacity Supplement, please

complete Parts 8 (a), (b), (c) and (d).
Part 8 Details for Incapacity Supplement
35.Do you wish to claim Incapacity Supplement?
Yes No
If ‘No’, please sign and date the Declaration in Part 1

If ‘Yes’, please answer the following questions.

36.Have you worked since your accident at work or the onset of the disease?
Yes No
If ‘Yes’, please give details below:
Employer 1
Employer’s name:

Employer’s address:

Period of work: From:

To:
D D M M Y Y Y Y
Type of work:

Gross weekly earnings: € , . a week

Employer 2
Employer’s name:

Employer’s address:

Period of work: From:

To:
D D M M Y Y Y Y
Type of work:

Gross weekly earnings: € , . a week

Part 8 (a) continued Details for Incapacity Supplement
Employer 3
Employer’s name:

Employer’s address:

Period of work: From:

To:
D D M M Y Y Y Y
Type of work:

Gross weekly earnings: € , . a week

Employer 4
Employer’s name:

Employer’s address:

Period of work: From:

To:
D D M M Y Y Y Y
Type of work:

Gross weekly earnings: € , . a week

37.Have you had any other earnings since the accident or disease?
Yes No
If ‘Yes’, please state:
Type of work:

Gross weekly earnings: € , . a week

Part 8 (a) continued Details for Incapacity Supplement
38.If you are getting any payment from this Department, please state:
Name of payment:
Your claim or reference
number:
Amount: € , . a week

39.If you are getting any payment from the Health Service Executive (for example, Supplementary
Welfare Allowance), please state:
Name of payment:
Your claim or reference
number:
Amount: € , . a week

40.If you are getting a pension or allowance from another country, please state:
Name of payment:
Your claim or reference
number:
Amount: € , . a week

41.If you are getting Jobseeker’s Benefit or Allowance, give name and address of local Social
Welfare Office:
Office name:

Office address:

42.Have you done any training or rehabilitation to prepare you for a different type of work since
you became disabled? Yes No
If ‘Yes’, please state:
Type of training:

Place of training:

Length of training: years months

Earnings: € , . a week

43.Do you live alone? Yes No

Part 8 (b) Details of your qualified child(ren)
44.How many children do under You must attach written confirmation
you wish to claim for? age 18 from the school or college for the
age 18 - 22 in full- children aged 18 - 22
time education
Please state child’s:
Surname:

First name(s):

PPS No.:

Surname:

First name(s):

PPS No.:

Surname:

First name(s):

PPS No.:

Surname:

First name(s):

PPS No.:

Surname:

First name(s):

PPS No.:
Note: A separate sheet of paper can be used for details of other children you have.
Part 8 (c) Your spouse’s or partner’s details

45.Their PPS No.:

46.Title: (insert an ‘X’ or Mr. Mrs. Ms. Other
specify)
47.Their surname:

48.Their first name(s):

49.Their birth surname:

50.Their mother’s birth
surname:
51.Their date of birth:
D D M M Y Y Y Y
52.Their address:
This question only applies if
you and your spouse or
partner no longer live at the
same address. • If you are paying maintenance, please attach copy of the
Maintenance Order.

Your spouse’s or partner’s work and claim

Part 8 (d)
details
53.If they are employed at present, please state:
Employer’s name:

Employer’s address:

Employer’s telephone MOBILE

number:
LANDLINE

Gross weekly earnings: € , . a week

Please attach their most recent payslip

54.If they are self-employed at present, please state:

Type of work they do:
0325588540
Date they started
self-employment:
D D M M Y Y Y Y
Net yearly earnings: € , . a year
This is the money they have made from self-employment after deducting operating expenses.
• Please enclose a copy of end of year accounts.
 Your spouse’s or partner’s work and claim
Part 8 (d)
details
55.If they have any other income please give details in this space provided:

56.If they are getting any payment from this Department, please state:
Name of payment:
Your claim or reference
number:
Amount: € , . a week

57.If they are getting any payment from the Health Service Executive (for example,
Supplementary Welfare Allowance), please state:
Name of payment:
Your claim or reference
number:
Amount: € , . a week

58.If they are getting a pension or allowance from another country, please state:
Name of payment:
Your claim or reference
number:
Amount: € , . a week

59.If they are getting Jobseekers Benefit or Allowance, give name and address of local Social
Welfare Office:
Office name:

Office address:

0325588540
 Details for the constant attendance
Part 9
allowance
Constant Attendance Allowance cannot be paid if a Carer's Allowance or Carer's Benefit
is in payment for the person requiring Care.
60.Do you wish to claim Constant Attendance Allowance?
Yes No
61.What are you unable to do because of your loss of faculty?

62.What does your attendant do for you?

63.Does she/he attend you daily?

Yes No

64.For how long does she/he hours a day

attend you each day?

65.For how long have you been in need of Constant Attendance?

years months

Applicant details (details of person providing full-time care)

Surname:

First name:

PPS No.:

Address:

0325588540
0325588540
 Warning: If you make a false statement or withhold information you may face a fine, a prison
term or both.

Send this completed application form to:

Disablement Benefit Section

Social Welfare Services
Government Buildings
Ballinalee Road
Longford

LoCall: 1890 92 77 70 (from the Republic of Ireland only)

Telephone: Dublin (01) 704 3000
+ 353 43 3340000 (from Northern Ireland or overseas)

Important: If you do not apply within 3 months you could lose benefit.

Note
The rates charged for using 1890 (LoCall) numbers may vary among different service providers.

0325588540 Data Protection Statement

Personal data is required to determine eligibility for payments and services, administered for
Ireland’s social protection system. It may be shared with other Government
Departments/Agencies where provided for by law. Data protection policy available at
www.welfare.ie/dataprotection or hard copy.
Explanations and terms used in this form are intended as a guide only and are not a legal interpretation.
00K 05-18 Edition: May 2018