Form BI100PD
Part 1: About you
Q1. Title
Guidance: For example, Mr, Ms, Mrs, Miss or other
Part 1: About you
Q2. Surname or family name
Part 1: About you
Q3. All other names In full
Part 1: About you
Q4. Any other surnames you have been known by or are using now
Guidance: Please include maiden name, all former married names and all changes of family name.
Part 1: About you
Q5. Address Postcode
Part 1: About you
Q6. Your mobile phone number
Part 1: About you
Q7. Daytime phone number, if you have one
Part 1: About you
Q8. Your email address, if you have one
Part 1: About you
Q9. Date of birth DD/MM/YYYY
Part 1: About you
Q10. National Insurance (NI) number
Guidance: You can find the number on your National Insurance (NI) numbercard, letters about your benefit or payslips.
Part 1: About you
Q11. If you do not know your NI number, have you ever had one or used one at any time?
Options: No; Yes
Part 1: About you
Q12. Your partner’s title
Guidance: For example, Mr, Ms, Mrs, Miss or other
Part 1: About you
Q13. Your partner’s surname or family name
Part 1: About you
Q14. All your partner’s other names In full
Part 1: About you
Q15. Your partner’s address Postcode
Part 1: About you
Q16. Your partner’s date of birth DD/MM/YYYY
Part 1: About you
Q17. Your partner’s National Insurance (NI) number
Guidance: You can find the number on their National Insurance (NI) numbercard, letters about their benefit or payslips.
Part 2: Consent
Q18. Do you give your consent for your doctor or other relevant professionals to give DWP more information about your health condition?
Options: Yes, information about my health can be shared with DWP or the health care professionals that work for them.; No, information about my health cannot be shared with DWP or the health care professionals that work for them.
Guidance: I have read and understood the text above
Part 3: Filling in the form and signing it for someone else
Q19. Please tell us why the claimant cannot fill in the form themselves
Guidance: Only complete this section if you are filling in the form for the claimant because they cannot do so or they have died.
Part 3: Filling in the form and signing it for someone else
Q20. If the person has died, please tell us when this happened
Guidance: Please send a copy of the death certificate with this form.
Part 3: Filling in the form and signing it for someone else
Q21. Title
Guidance: For example, Mr, Ms, Mrs, Miss or other
Part 3: Filling in the form and signing it for someone else
Q22. Surname or family name
Part 3: Filling in the form and signing it for someone else
Q23. All other names In full
Part 3: Filling in the form and signing it for someone else
Q24. What is your relationship to the claimant?
Part 3: Filling in the form and signing it for someone else
Q25. Address Postcode
Part 3: Filling in the form and signing it for someone else
Q26. Mobile phone number
Part 3: Filling in the form and signing it for someone else
Q27. Daytime phone number, if you have one
Part 3: Filling in the form and signing it for someone else
Q28. Email address
Part 3: Filling in the form and signing it for someone else
Q29. Date of birth DD/MM/YYYY
Part 3: Filling in the form and signing it for someone else
Q30. National Insurance (NI) number
Guidance: You can find the number on your National Insurance (NI) numbercard, letters about your benefit or payslips.
Part 4: About your work or your approved employment training scheme or course and your disease
Q31. Which disease do you have?
Part 4: About your work or your approved employment training scheme or course and your disease
Q32. Please state the prescribed disease number if you know it
Part 4: About your work or your approved employment training scheme or course and your disease
Q33. On what date do you think you started to suffer from the disease? If you are not sure of the date, give an approximate date
Part 4: About your work or your approved employment training scheme or course and your disease
Q34. What type of work or training do you think caused your disease?
Part 4: About your work or your approved employment training scheme or course and your disease
Q35. In what way has the disease affected you?
Part 4: About your work or your approved employment training scheme or course and your disease
Q36. Name of the employer or training provider where you did the work
Part 4: About your work or your approved employment training scheme or course and your disease
Q37. Employer’s or training provider’s address Postcode
Part 4: About your work or your approved employment training scheme or course and your disease
Q38. If your employer or training provider has changed their name or address since you worked there, please tell us the new details
Part 4: About your work or your approved employment training scheme or course and your disease
Q39. In which business area is this company involved?
Part 4: About your work or your approved employment training scheme or course and your disease
Q40. Is this employer or training provider still in business?
Options: No; Yes
Part 4: About your work or your approved employment training scheme or course and your disease
Q41. If you were on an approved employment training course, who sent you on it?
Guidance: For example, Jobcentre Plus or another organisation.
Part 4: About your work or your approved employment training scheme or course and your disease
Q42. Were you employed by an agency?
Options: No; Yes
Part 4: About your work or your approved employment training scheme or course and your disease
Q43. Employer’s or training provider’s phone number
Part 4: About your work or your approved employment training scheme or course and your disease
Q44. Employer’s or training provider’s email address
Part 4: About your work or your approved employment training scheme or course and your disease
Q45. Workplace
Part 4: About your work or your approved employment training scheme or course and your disease
Q46. When did you work there? If you are not sure of the dates, give an approximate date From To
Part 4: About your work or your approved employment training scheme or course and your disease
Q47. Your job title
Part 4: About your work or your approved employment training scheme or course and your disease
Q48. Payroll, staff or other employment reference number
Part 4: About your work or your approved employment training scheme or course and your disease
Q49. If you were on a training course, what type of training course were you on?
Part 4: About your work or your approved employment training scheme or course and your disease
Q50. Name of the employer or training provider where you did the work
Part 4: About your work or your approved employment training scheme or course and your disease
Q51. Employer’s or training provider’s address Postcode
Part 4: About your work or your approved employment training scheme or course and your disease
Q52. If your employer or training provider has changed their name or address since you worked there, please tell us the new details
Part 4: About your work or your approved employment training scheme or course and your disease
Q53. In which business area is this company involved?
Part 4: About your work or your approved employment training scheme or course and your disease
Q54. Is this employer or training provider still in business?
Options: No; Yes
Part 4: About your work or your approved employment training scheme or course and your disease
Q55. If you were on an approved employment training course, who sent you on it?
Guidance: For example, Jobcentre Plus or another organisation.
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q56. Were you employed by an agency?
Options: No; Yes
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q57. Employer’s or training provider’s phone number
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q58. Employer’s or training provider’s email address
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q59. Workplace
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q60. When did you work there? If you are not sure of the dates, give an approximate date From To
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q61. Your job title
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q62. Payroll, staff or other employment reference number
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q63. If you were on a training course, what type of training course were you on?
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q64. Have you ever claimed Industrial Injuries Disablement Benefit for any other industrial disease or for an industrial accident?
Options: No; Yes
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q65. If you claimed for an industrial disease before, what is the name of the disease?
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q66. If you claimed for an industrial accident before, what was the date of the accident?
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q67. When did you claim? If you are not sure, give an approximate date.
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q68. If you claimed for an industrial disease before, what is the name of the disease?
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q69. If you claimed for an industrial accident before, what was the date of the accident?
Part 5: About earlier claims for Industrial Injuries Disablement Benefit
Q70. When did you claim? If you are not sure, give an approximate date.
Part 6: About medical details
Q71. Are you claiming for D3 - diffuse mesothelioma D8 - primary carcinoma of the lung D8A - primary carcinoma of the lung D10 - primary carcinoma of the lung D11 - primary carcinoma of the lung C4 - primary carcinoma of the bronchus or lung, or C22(b) - primary carcinoma of the bronchus or lung, or C24(a) - angiosarcoma of the liver with evidence of asbestosis because of the disease?
Options: No; Yes
Guidance: Please tell us about the hospital or clinic you have been to because of the disease. If you need to tell us about more than one hospital or clinic, tell us about them in Part 9 Other information.
Part 6: About medical details
Q72. GP’s name
Part 6: About medical details
Q73. GP’s address Postcode
Part 6: About medical details
Q74. GP’s phone number If you know it
Part 6: About medical details
Q75. Have you attended a hospital or clinic with evidence of asbestosis because of the disease?
Options: No; Yes
Guidance: Please read page 8 of B I100PD Notes.
Part 6: About medical details
Q76. Name of the hospital or clinic
Part 6: About medical details
Q77. Hospital or clinic address Postcode
Part 6: About medical details
Q78. Department or ward
Part 6: About medical details
Q79. Reference number or admission number
Part 6: About medical details
Q80. Name of specialist If you know their name
Part 6: About medical details
Q81. Dates of treatment From To
Part 6: About medical details
Q82. Did you have an x-ray?
Options: No; Yes
Part 6: About medical details
Q83. We may ask you to go for an assessment with a doctor or health care professional
Guidance: If you have any problems with going for an assessment, please tell us about them. Please provide full details of why you need a home visit, and send us any medical evidence you already have to support this request. Do not ask or pay for new evidence. Also tell us any dates and times that you may not be able to go for a medical assessment in the next 6 months.
Part 7: About other benefits and entitlements
Q84. Are you getting either a War Disablement Pension or a payment from the Armed Forces Compensation Scheme?
Options: You are getting a War Disablement Pension; You are getting Armed Forces Compensation Scheme payments
Part 8: How we pay you
Q85. Please tell us how often you want us to pay your Industrial Injuries Disablement Benefit
Options: Every week – in advance; Every 4 weeks – in arrears; Every 13 weeks – in arrears
Guidance: If you want more information, get in touch with the Industrial Injuries Disablement Benefit office. You can find the office mailing addresses and contact phone number at the end of the BI 100PD Notes which we sent you with this form.
Part 8: How we pay you
Q86. Name of the account holder
Guidance: Please tell us the name of the account holder exactly as it is shown on the bank card or account statement.
Part 8: How we pay you
Q87. Name of the bank or building society
Part 8: How we pay you
Q88. Sort code
Guidance: Tell us all 6 numbers, for example 12-23-56.
Part 8: How we pay you
Q89. Account number
Guidance: This must be between 6 and 10 numbers.
Part 8: How we pay you
Q90. Building society roll or reference number
Guidance: You may get other benefits and entitlements we do not pay into an account. If you want us to pay them into the account above, please tick this box.
Part 9: Other information
Q91. Please use this space to tell us anything else you think we might need to know.
Guidance: If there is not enough space, please use a separate sheet of paper. Make sure that you: • put your full name and National Insurance number on each sheet of paper, and • sign and date each sheet that you use.
Part 10: Declaration
Q92. I declare I understand Industrial Injuries Disablement Benefit Notes, and that the information provided on this claim form is correct and complete.
Guidance: To make sure you get the benefit you are entitled to, it is important that the information you provide is correct and complete. You will be asked to sign this form to declare the answers you have given are correct. • I understand that I must report all changes in my circumstances which may affect my entitlement promptly and by failing to do so I may be liable to prosecution or face a financial penalty. • I will phone or write to the office that pays my benefit to report a change of circumstances. • I understand if I give false or incomplete information or fail to report changes in my circumstances promptly, my Industrial Injuries Disablement Benefit may be stopped or reduced and any overpayment of Industrial Injuries Disablement Benefit may be recovered. In addition I may be prosecuted or face a financial penalty.
Part 10: Declaration
Q93. Signature
Part 10: Declaration
Q94. Date DD/MM/YYYY