Injury Grant
Application Form – HR 112
This form is used to apply for a the payment of Injury Grant under Article 49/109 of the Local
Government (Superannuation) (Consolidation) Scheme 1998 in respect of an injury sustained while
performing official duties. Please complete form in Block Capitals/Tick appropriate boxes
HR 112_V2 Apr 2010 Page 1 of 3 Revised 01/04/2010
Part 1.
Section 1 Personal Details (To be completed by the employee)
Name
Personnel No
PPS No
Grade/Occupation Service
Address for HSE correspondence
Tel No: Mobile No:
I understand that should my application be successful, that any period for which I am in receipt of an injury
grant will not be included as service for pension benefit purposes.
Section 2 - Accident Details (To be completed by the Line Manager)
Date of accident
Time of Accident
(24 HR Clock)
Place where accident happened?
Details of Accident:
Signature
Date
Nature of Injuries
:
(Attach a copy of
medical certificate or
death certificate in the
case of a fatality)
Was the employee authorised to be at the place of the accident for the purpose of
his/her work?
Yes
No
Date accident first reported to HSE?
To who was the accident reported?
Was an investigation of the accident carried out: Yes No
By whom was the accident
investigated (attach copies of Incident
Report Form, Occupational Health and
other relevant reports, witnesses
statements, etc)
Section 3 – Witnesses Details (To be completed by Line Manager)
Name: Grade
Address
Tel No: Mobile No:
Name: Grade
Address
Tel No: Mobile No:
Name: Grade
Address
Tel No: Mobile No:
Line Manager Name (print) Job Title
Contact Tel. No:
Signature:
Date
HR 112_V2 Apr 2010 Page 2 of 3 Revised 01/04/2010
What was the employee
doing at the time of the
Accid
ent?
HR 112_V2 Apr 2010 Page 3 of 3 Revised 01/04/2010
Part 2 To be completed by Senior Manager/General Manager
Under the terms of Article 49/109 of the Local Government (Superannuation) (Consolidation) Scheme 1998
I recommend that the payment of the injury grant is granted in this case
I refuse this application
Comments: (if application is refused, state reason)
Senior Manager Name: Job Title
Signature Date
Part 3 To be completed by Assistant Director of Human Resource
Under the terms of Article 49/109 of the Local Government (Superannuation) (Consolidation) Scheme 1998 be
invoked in this case to provide for the payment of Injury Grant
I recommend this application I refuse this application
Comments: (if application is refused, state reason)
Name:
Assistant Director of HR
Signature: Date
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