Health and Safety Benefit Application Form (HSB1)

• Published date: 26 April 2021
• Issuer: Department of Social Protection

How to complete this application form.

• 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.

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

Employee:

If you are an employee fill in Parts 1, 2, 3, 5, 7 and 8 as they apply to you. When

form is completed, read Part 9 and sign declaration in Part 1.

Employer:

If you are an employer fill in Part 4. Please make sure you sign and stamp this

part of the form.

Self-employment does not qualify for Health and Safety Benefit.

Doctor:

Please fill in Part 6 of the form. Please make sure you sign and stamp this part of

the form.

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.

Important:

If you do not submit this form within 6 months of becoming eligible you could

lose benefit.

Application form for

Health and Safety Benefit

Data Classification R

Social Welfare Services

HSB 1