Sickness Assistance









This application may also be used for Leprosy Assistance and Tuberculosis Assistance
Please Select:*	This application is for a new case This application is for another person

Please Select:*
Details of Head of Household
Identity Card Number:*
Name:*
Surname:*
Date of Birth (DD/MM/YYYY):*
Civil Status:*
Nationality:*
Mobile:
Telephone:
E-mail:
Contact Details
Address:*
Details about the Head of Household's / Spouse's Employment
Is the Head of Household employed:*
If Yes:
If Head of Household is employed on Part-Time basis, kindly attach copy of last Payslip:

Is Spouse Employed:
If Yes:
If Spouse is employed on Part-Time basis, kindly attach copy of last Payslip:
If you were Employed
Employer's Details

Name:
Surname:
Address:
What was your grade?:

Remuneration / Gratuity received on termination of employment €:
If you were Gainfully Occupied

Do you still have the permit?:
What has been done with the machinery and / or stock?:
What has been done with the business premises?:
Date of Termination (DD/MM/YYYY):
Details of the Household's Capital Resources and Income (required for Sickness Assistance only)
Bank Deposits / Funds held in local and foreign banks. (Quote Bank Account numbers or other references)

Bank:
Type of Account:
Account Number:
Account Holder:
Amount €:
Interest %:

Bank:
Type of Account:
Account Number:
Account Holder:
Amount €:
Interest %:

Bank:
Type of Account:
Account Number:
Account Holder:
Amount €:
Interest %:

Bank:
Type of Account:
Account Number:
Account Holder:
Amount €:
Interest %:

Bank:
Type of Account:
Account Number:
Account Holder:
Amount €:
Interest %:
Money kept at home, lent to or kept by third parties (required for Sickness Assistance only)
Please give details:
Urban or Rural Properties (Do not include house of residence or summer residence) (required for Sickness Assistance only)
Please Select:	Vacant Property Rented Property Cultivated Land Uncultivated Land
Annual Income €:
Pensions (Do not include Head of Household’s Social Security Pension) (required for Sickness Assistance only)

Name of Pensioner:
Type of Pension:
Annual Income €:

Name of Pensioner:
Type of Pension:
Annual Income €:

Name of Pensioner:
Type of Pension:
Annual Income €:

Name of Pensioner:
Type of Pension:
Annual Income €:
Other Income (required for Sickness Assistance only)
Privileges or other similar income including all forms of annuity and maintenance €:
Other income not mentioned above €:
Details about the Family Setup
Head of Household Details

Indicate Details about - (a) Employment or Income Source:
Indicate Details about - (b) Benefit being received:
Weekly Gross Income €:
Family Details

Identity Card Number:
Name:
Surname:
Date of Birth (DD/MM/YYYY):
Relation to Head of Household:
Indicate Details about - (a) Employment or Income Source:
Indicate Details about - (b) Benefit being received:
Weekly Gross Income €:

Identity Card Number:
Name:
Surname:
Date of Birth (DD/MM/YYYY):
Relation to Head of Household:
Indicate Details about - (a) Employment or Income Source:
Indicate Details about - (b) Benefit being received:
Weekly Gross Income €:

Identity Card Number:
Name:
Surname:
Date of Birth (DD/MM/YYYY):
Relation to Head of Household:
Indicate Details about - (a) Employment or Income Source:
Indicate Details about - (b) Benefit being received:
Weekly Gross Income €:

Identity Card Number:
Name:
Surname:
Date of Birth (DD/MM/YYYY):
Relation to Head of Household:
Indicate Details about - (a) Employment or Income Source:
Indicate Details about - (b) Benefit being received:
Weekly Gross Income €:

Identity Card Number:
Name:
Surname:
Date of Birth (DD/MM/YYYY):
Relation to Head of Household:
Indicate Details about - (a) Employment or Income Source:
Indicate Details about - (b) Benefit being received:
Weekly Gross Income €:
Bank Account Details
Do you have a bank Garnishee Order?:*

If you have a bank garnishee order, provide an official document and payment will be made by cheque. If you do not have a bank garnishee order, fill in the below bank details.
Copy of Garnishee Order if you have blocked Bank Accounts:

Allowance should be deposited in a Savings or Current Account, but not in a Loan Account. The indicated account has to be in the name of the beneficiary.
Bank:
IBAN:

Enter Mobile Number for an SMS notification regarding payment:
Necessary Documents
Copies of Stocks and Shares
Stocks:
Shares:
An official document from an Architect declaring the current capital value of any mentioned unrented property
Document from an Architect:
Copy of the Land Registration Booklet
Land Registration Booklet:
Copy of document showing actual income from foreign pensions
Income from Foreign Pensions:
Copy of rent documents for any rented property
Rented Property:
Details about the Patient (To be filled by Medical Doctor and attach document)
Doctor's Report:*
Declaration
Signed Declaration Form:*
To receive a copy of the application, type your email address below

EmailAddress: