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    Ni4 PDF

    Uploaded by

    Ryan Noel Bissoon
    The document provides instructions for registering as an employed person with the National Insurance Board, requiring personal details such as name, date of birth, occupation, employer information, and a declaration certifying the accuracy of the information provided. Late registration or failure to provide required information could result in fines or problems processing national insurance contributions and claims. Applicants must have their information verified by their employer before signing to declare the truth of their statements.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Ni4 PDF

    Uploaded by

    Ryan Noel Bissoon
    292 views2 pages
    The document provides instructions for registering as an employed person with the National Insurance Board, requiring personal details such as name, date of birth, occupation, employer information, and a declaration certifying the accuracy of the information provided. Late registration or failure to provide required information could result in fines or problems processing national insurance contributions and claims. Applicants must have their information verified by their employer before signing to declare the truth of their statements.

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    The document provides instructions for registering as an employed person with the National Insurance Board, requiring personal details such as name, date of birth, occupation, employer information, and a declaration certifying the accuracy of the information provided. Late registration or failure to provide required information could result in fines or problems processing national insurance contributions and claims. Applicants must have their information verified by their employer before signing to declare the truth of their statements.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    292 views2 pages

    Ni4 PDF

    Uploaded by

    Ryan Noel Bissoon
    The document provides instructions for registering as an employed person with the National Insurance Board, requiring personal details such as name, date of birth, occupation, employer information, and a declaration certifying the accuracy of the information provided. Late registration or failure to provide required information could result in fines or problems processing national insurance contributions and claims. Applicants must have their information verified by their employer before signing to declare the truth of their statements.

    Copyright:

    © All Rights Reserved
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    of 2

    THE NATIONAL INSURANCE BOARD NI 4

    THE NATIONAL INSURANCE REGISTRATION REGULATIONS


    APPLICATION TO REGISTER AS AN EMPLOYED PERSON
    (Other than Self-employed)

    INSTRUCTIONS
    1. Please TYPE or complete in BLOCK LETTERS.

    2. Employers must register employed persons and apprentices within 14 days of employment. Late registration could result in a fine.

    3. The law requires that you furnish your employer with the personal particulars necessary to complete this form.

    4. All questions must be answered: if you do not know your Father's name or Mother's maiden name, the words "not known" must be
    inserted on the respective lines.

    5. Proper recording of your National Insurance Contributions and prompt and accurate settlement of your claims cannot be achieved if you do
    not provide the information required on this form.

    6. Read the Declaration at the back carefully and sign in the space provided. FOR OFFICIAL USE
    LOCAL OFFICE NO.:

    ALL INFORMATION MUST BE VERIFIED BY YOUR EMPLOYER


    NATIONAL INSURANCE NO.:

    1. Surname: First Name:

    Middle Name:

    2. Name at birth if different from above: (Changed by Deed Poll, Marriage)


    Surname: First Name:

    3. Other names by which known:


    Surname: First Name:

    4. Are you an apprentice? Yes No Telephone No.: --

    5. Gender: Female Male

    6. Home Address:
    STREET

    CITY/DISTRICT/COUNTY

    7. Date of Birth: 8. Place of Birth:


    YYYY MM DD
    STREET

    9. Multiple Birth: Yes No


    CITY/DISTRICT/COUNTY
    If "Yes", please state name of siblings.

    Surname: Other Name(s):

    Surname: Other Name(s):

    10. Any Family members with same name? Yes No


    If "Yes", please state relationship and Date of Birth:.

    Relationship: Date of Birth:


    YYYY MM DD

    Relationship: Date of Birth:


    YYYY MM DD

    01/2009
    2/NI4
    11. Father's Name:

    Surname: First Name:

    12. Mother's Maiden Name:

    13. Valid Identification Document (one Only): 13b. Expiry Date:


    Electoral Identification Card Passport Driver's Permit YYYY MM DD

    Number:

    14. Marital Status: Single Married Separated

    Widowed Divorced Common Law

    15. If Marital Status is Common Law, please give particulars of Common Law Spouse:
    Name of Common Law Spouse:

    Surname: First Name:

    16. Business Name of Employer:

    17. Address of Employer:


    STREET

    CITY/DISTRICT/COUNTY

    Daily
    18. Occupation: 19. Pay Frequency:
    Weekly Amount $

    20. First Date of Employment: Fortnightly


    YYYY MM DD Monthly

    21. Have you been previously registered? Yes No If "Yes", state N.I. Number:

    22. Are you currently employed elsewhere? Yes No


    If "Yes", state Business Name and Address of Other Employer:

    Business Name of Employer:

    Address of Employer:
    STREET

    CITY/DISTRICT/COUNTY

    CERTIFICATE OF DECLARANT
    I solemnly and sincerely declare that I am the applicant named herein and that the particulars set out in this application are true.
    I make this declaration conscientiously believing same to be true and I am aware that if there 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 be true, I am liable on summary conviction to a
    fine of three thousand dollars ($3,000.00) and to imprisonment for two years in accordance with Sect 33, NI Act Chap 32:01.

    Employer's Registration No:


    Declared this
    YYYY MM DD

    Signature or Mark of Declarant Signature or Witness to Mark

    Was information verified by Employer? Yes No

    COMPANY STAMP

    SIGNATURE OF EMPLOYER DESIGNATION

    01/2009

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