Form BI100OD
About you
Q1. First name
About you
Q2. Last name
About you
Q3. National Insurance (N I) number
About your employment or approved training scheme or course
Q4. Have you used any of these tools or machines or have you worked close to someone using them? Powered, but not hand powered, grinding tools used on metal other than sheet metal or plate metal
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q5. Band saws, circular saws or cutting discs for cutting metal in the metal founding or forging industries
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q6. Circular saws for cutting products in the manufacture of steel
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q7. Burners or torches for cutting or dressing steel-based products
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q8. Pneumatic percussive tools: On metal
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q9. Machines engaged in cutting, shaping or cleaning metal nails for cleaning
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q10. Plasma spray guns to spray molten metal
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q11. Vibrating metal moulding boxes in the concrete products industry
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q12. Firearms as a police firearms training officer
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q13. Automatic moulding, automatic blow moulding or automatic glass pressing and forming machines used in the manufacture of glass containers or hollow ware
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q14. Circular saws for cutting concrete masonry blocks
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q15. Spinning machines using compressed air to produce glass wool or mineral wool
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q16. Continuous glass toughening furnaces
Options: Used; Not worked in the process, but worked close to someone else working in it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q17. Have you ever worked in textile manufacturing in rooms or sheds where there are machines engaged in: Weaving man-made or natural, including mineral, fibres?
Options: Worked in the process; Not worked in the process, but worked close to someone else working in it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q18. Have you ever used or worked close to a plant (excluding power press plant) engaged in the forging (including drop stamping) of metal by means of Closed or open dies?
Options: Worked in the process; Not worked in the process, but worked close to someone else working in it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q19. Drop hammers? Planing machines
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q20. Have you ever used any of these machines, or worked close to someone using these machines on wood or material made partly of wood? Automatic or semi-automatic lathes
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q21. Have you ever used, or worked close to, high pressure jets of water, or a mixture of water and abrasive material?
Options: Used; Not used, but worked close to someone using it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q22. Have you ever worked in any of these processes, or worked close to someone else working in any of these processes: Mechanical cleaning of bobbins? Air arc gouging?
Options: Worked in the process; Not worked in the process but worked close to someone else working in it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q23. Have you ever worked on gas turbines used for: Performance testing on test bed? Burning stone in quarries by jet channeling processes?
Options: Worked in the process; Not worked in the process but worked close to someone else working in it
Guidance: Tell us the distance feet
Number of hours daily hours
About your employment or approved training scheme or course
Q24. Have you worked in the area of skid-transfer banks in a steel mill?
Options: Yes; No
Guidance: Number of hours daily hours
Tell us the distance feet
About your employment or approved training scheme or course
Q25. Have you worked in the area of knock-out and shake-out grids in foundries?
Options: Yes; No
Guidance: Number of hours daily hours
Tell us the distance feet
About your employment or approved training scheme or course
Q26. Have you ever worked in a ships engine room?
Options: Yes; No
Guidance: Number of hours daily hours
Tell us the distance feet
Declaration
Q27. Declaration
Guidance: • I declare I understand Industrial Injuries Disablement Benefit Notes, and that the information provided on this claim form is correct and complete.
• 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.
Declaration
Q28. Date
Guidance: DD/MM/YYYY