Form BI100A
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
Guidance: 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
Part 1: About you
Q6. Mobile phone number
Part 1: About you
Q7. Daytime phone number
Guidance: If you have one.
Part 1: About you
Q8. Email address
Part 1: About you
Q9. Date of birth
Guidance: DD/MM/YYYY
Part 1: About you
Q10. National Insurance (N I) number
Guidance: You can find the number on your National Insurance (N I) numbercard, letters about your benefit or wage slips.
Part 1: About you
Q11. If you do not know your N I 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 of your partner’s other names
Guidance: In full.
Part 1: About you
Q15. Your partner’s address
Part 1: About you
Q16. Your partner’s date of birth
Guidance: DD/MM/YYYY
Part 1: About you
Q17. Your partner’s National Insurance (N I) number
Guidance: You can find the number on your National Insurance (N I) numbercard, letters about your benefit or wage slips.
Part 2: Consent
Q18. Do you give consent for your doctor or other relevant professionals to give DWP more information about your health condition?
Options: No, information about my health cannot be shared with DWP or the health care professionals that work for them.; Yes, information about my health can be shared with DWP or the health care professionals that work for them.
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: DD/MM/YYYY
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
Guidance: 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
Part 3: Filling in the form and signing it for someone else
Q26. Your mobile phone number
Part 3: Filling in the form and signing it for someone else
Q27. Your daytime phone number
Guidance: If you have one.
Part 3: Filling in the form and signing it for someone else
Q28. Your email address
Part 3: Filling in the form and signing it for someone else
Q29. Date of birth
Guidance: DD/MM/YYYY
Part 3: Filling in the form and signing it for someone else
Q30. National Insurance (N I) number
Guidance: You can find the number on your National Insurance (N I) numbercard, letters about your benefit or wage slips.
Part 4: About your work or your approved employment training scheme or course
Q31. Name of the employer or training provider at the time of the accident
Guidance: For example, Jobcentre Plus or another organisation.
Part 4: About your work or your approved employment training scheme or course
Q32. Employer’s or training provider’s address
Part 4: About your work or your approved employment training scheme or course
Q33. If your employer or training provider has changed their name or address since your accident, please tell us the new details
Part 4: About your work or your approved employment training scheme or course
Q34. In which business area is this company involved?
Part 4: About your work or your approved employment training scheme or course
Q35. 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
Q36. If you were on an approved employment training course, who sent you on it?
Part 4: About your work or your approved employment training scheme or course
Q37. Were you employed by an agency?
Options: No; Yes
Guidance: If you were employed by an agency please provide their name and address
Part 4: About your work or your approved employment training scheme or course
Q38. Employer’s or training provider’s phone number
Part 4: About your work or your approved employment training scheme or course
Q39. Employer’s or training provider’s email address
Part 4: About your work or your approved employment training scheme or course
Q40. Workplace
Part 4: About your work or your approved employment training scheme or course
Q41. When did you work there?
Guidance: This means when you actually went to work. If you were employed by the company but were off work sick, please enter the date when you last went to work. If you are not sure of the dates, give an approximate date.
Part 4: About your work or your approved employment training scheme or course
Q42. Your job title
Part 4: About your work or your approved employment training scheme or course
Q43. Payroll, staff or other reference number
Part 4: About your work or your approved employment training scheme or course
Q44. If you were on a training course, what type of training course were you on?
Part 5: About the accident
Q45. What date and time did the accident happen?
Guidance: Please send in your wage slip for this date. DD/MM/YYYY
Part 5: About the accident
Q46. Where at work did the accident happen?
Guidance: Please tell us the exact place where it happened.
Part 5: About the accident
Q47. Have you reported the accident to your employer or training provider?
Options: No; Yes
Guidance: Please send us a copy of the accident report. Please tell them about the accident now.
Part 5: About the accident
Q48. If you were employed by an agency did you report the accident to the agency?
Options: No; Yes
Part 5: About the accident
Q49. Have you ever claimed benefit under an Industrial Injuries Scheme for this accident in the past?
Options: No; Yes
Guidance: Please tell us when.
Part 5: About the accident
Q50. Have you ever contacted us about this accident?
Options: No; Yes
Guidance: Please tell us when.
Part 6: Details of the accident
Q51. What was the accident and how did it happen? What were you doing when the accident happened?
Guidance: Please give as much information as you can.
Part 6: Details of the accident
Q52. Please describe the injuries caused by the accident
Guidance: Please give as much information as you can. For example, if you injured an arm, tell us if it was your left or your right arm.
Part 6: Details of the accident
Q53. In what way has the accident affected you?
Guidance: Please let us know how the injury has affected you since the accident. Also, how is this currently affecting you? Provide details of any employment since your accident.
Part 7: About earlier claims for Industrial Injuries Disablement Benefit
Q54. Have you ever claimed Industrial Injuries Disablement Benefit for any other industrial disease or for an industrial accident?
Options: No; Yes
Guidance: Go to Part 8
Part 7: About earlier claims for Industrial Injuries Disablement Benefit
Q55. If you claimed for an industrial accident before, what was the date of the accident?
Guidance: If you are not sure, give an approximate date.
Part 7: About earlier claims for Industrial Injuries Disablement Benefit
Q56. If you claimed for an industrial disease before, what is the name of the disease?
Part 7: About earlier claims for Industrial Injuries Disablement Benefit
Q57. When did you claim?
Guidance: If you are not sure, give an approximate date.
Part 7: About earlier claims for Industrial Injuries Disablement Benefit
Q58. If you claimed for an industrial accident before, what was the date of the accident?
Part 7: About earlier claims for Industrial Injuries Disablement Benefit
Q59. If you claimed for an industrial disease before, what is the name of the disease?
Part 7: About earlier claims for Industrial Injuries Disablement Benefit
Q60. When did you claim?
Guidance: If you are not sure, give an approximate date.
Part 8: About medical details
Q61. GP’s name
Part 8: About medical details
Q62. GP’s address
Part 8: About medical details
Q63. GP’s phone number, if you know it
Part 8: About medical details
Q64. Have you attended a hospital or clinic, because of the accident?
Options: No; Yes
Guidance: Go to question 72
Part 8: About medical details
Q65. Name of hospital or clinic
Part 8: About medical details
Q66. Address of hospital or clinic
Part 8: About medical details
Q67. Reference number or admission number
Part 8: About medical details
Q68. Department or ward
Part 8: About medical details
Q69. Name of specialist
Guidance: If you know their name
Part 8: About medical details
Q70. Dates of treatment
Guidance: DD/MM/YYYY
Part 8: About medical details
Q71. Did you have an x-ray?
Options: No; Yes
Part 8: About medical details
Q72. 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 tell us if you can travel by taxi or if a friend or relative can give you a lift. 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.
Part 9: About other benefits
Q73. Tell us any dates and times that you may not be able to go for a medical assessment in the next 6 months.
Part 9: About other benefits
Q74. Are you, or your partner if you have one, getting either a War Disablement Pension or a payment from The Armed Forces Compensation Scheme?
Options: War Disablement Pension; Armed Forces Compensation Scheme
Guidance: We use partner to mean: • a person you live with who is your husband, wife or civil partner, or • a person you live with as if you are a married couple.
Part 10: How we pay you
Q75. Please tell us how often you want us to pay your benefit
Options: Every week; Every 4 weeks; Every 13 weeks
Guidance: This means we will have paid you money that may be less than you are entitled to. Sometimes we may not be able to change the amount we have already paid you. If you want more information, get in touch with the Industrial Injuries Disablement Benefit office. You can find the office mailing addresses and contact telephone number in the B I100 A Notes which we sent you with this form.
Part 10: How we pay you
Q76. 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 10: How we pay you
Q77. Name of bank or building society
Part 10: How we pay you
Q78. Sort code
Guidance: Tell us all 6 numbers, for example 12‑34‑56.
Part 10: How we pay you
Q79. Account number
Guidance: Most account numbers are 8 numbers long. If your account number has fewer than 10 numbers, please fill in the numbers from the left.
Part 10: How we pay you
Q80. Building society roll or reference number
Guidance: If you are using a building society account you may need to tell us a roll or reference number. This may be made up of letters and numbers, and may be up to 18 characters long. If you are not sure if the account has a roll or reference number, ask the building society.
Part 11: Other information
Q81. 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 12: Declaration
Q82. I declare I understand Industrial Injuries Disablement Benefit Notes, and that the information provided on this claim form is correct and complete.
Part 12: Declaration
Q83. 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.
Part 12: Declaration
Q84. I will phone or write to the office that pays my benefit to report a change of circumstances.
Part 12: Declaration
Q85. 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 12: Declaration
Q86. This is my claim for Industrial Injuries Disablement Benefit.
Part 12: Declaration
Q87. Signature
Part 12: Declaration
Q88. Date
Guidance: DD/MM/YYYY