Disablement Benefit or Incapacity Supplement Application Form (OB21)

• Published date: 20 February 2020
• Issuer: Department of Social Protection

How to complete application form for Disablement Benefit and/or Incapacity

Supplement under the Occupational Injuries Scheme.

• Please tear off this page and use 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. If a question does not apply to

you, please leave the answer area blank.

• You need a Personal Public Service Number (PPS No.) before you apply.

If you are applying because of an accident at work, complete Parts 1, 2, 3, 4, 7

and have your employer fill in Part 5. When the form is complete, sign

the declaration in Part 1.

If you are applying because of a work-related disease, complete Parts 1, 2, 3, 6, 7

and have your employer fill in Part 5. When the form is complete, sign the

declaration in Part 1.

If you also want to claim Incapacity Supplement, complete Part 8 too. When the

form is complete, sign the declaration in Part 1.

If you also want to claim Constant Attendance Allowance, complete Part 9 too.

When the form is complete, sign the declaration in Part 1.

If you need any help to complete this form, please contact your local Social

Welfare Office or Citizens Information Centre.

For more information, log on to www.gov.ie.

OB21

Social Welfare Services

Application form for

Disablement Benefit and/or Incapacity

Supplement under the Occupational Injuries

Scheme

How to fill in first page of this form

To help us in processing your application:

• Print letters and numbers clearly.

• Use one box for each character (letter or number).

Please see example below.

SAMPLE

1234567T

M U R P H Y

M A U R E E N

M C D E R M O T T

1 N E W S T R E E T

O L D T O W N

C O D O N E G A L

L A N D L I N E

M O B I L E

017043000

0841234567

2 8 0 2 1 9 7 0

M M U R P H Y @ W E L F A R E . I E

1. Your PPS No.:

3. Surname:

8. Your date of birth:

4. First name(s):

D D M M Y Y Y Y

Mr. Mrs. Ms. Other

2. Title: (insert an ‘X’ or

specify)

6. Birth surname:

5. Your first name as it

appears on your birth

certificate:

10.Your telephone number:

11.Your email address:

Contact Details

9. Your address:

X

M A R Y

7 . Your mother’s birth

surname: K E L L Y