Death Benefit under the Occupational Injuries Scheme Application Form (OB61)

Published date19 February 2020
IssuerDepartment of Social Protection
OB 61
Social Welfare Services
Data Classification R
Application form for
Death Benefits under the
Occupational Injuries Scheme
You need a Personal Public Service Number (PPS No.) before you apply.
How to complete this application:
Please use this page as a guide to filling in this form.
Please use BLACK ball point pen.
Please use BLOCK LETTERS and place an X in the relevant boxes.
Please answer all questions that apply to you.
Widow, Widower or Surviving Civil Partner complete Parts 1 to 6 of this form.
When form is completed, read Part 7 and sign declaration in Part 1.
Orphan’s Pension complete Parts 1 to 5. When form is completed, read Part 7
and sign declaration in Part 1.
Funeral Grant complete Parts 1 to 5. When form is completed, read Part 7 and
sign declaration in Part 1.
If you need any help to complete this form, please contact your local Citizens
Information Centre, your local Intreo Centre or your local Social Welfare Office.
For more information, log on to www.gov.ie.
Important:
You must apply within 3 months of the date of death, otherwise you may lose
payment.
You must enclose a death certificate with this application.

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