3. Date of Birth (dd/mm/yyyy)
4. Gender
7. P.O. Box No.
6. Home Address
8. E-mail Address
Male Female
5. Occupation
Section A: Insured Person's Details
1. Social Security No.
Section B: Employment History
10. Name of Current Employer
17. Are you currently employed?
Yes No
20. Are you in receipt of any Social Security Benefits?
Yes No
12. Date Last Employed (dd/mm/yyyy)
14. Period Employed from: (dd/mm/yyyy) To: (dd/mm/yyyy)
15. Name of Secondary Employer
16. Period Employed was from: (dd/mm/yyyy) To: (dd/mm/yyyy)
Section C: Eligibility
18. Are you self-employed?
Yes No
Yes No
Yes No
If yes; state the type of Benefit?
13. Last pay date (dd/mm/yyyy)
The above information will be used to update your permanent records
9. Tel./Cellular No.
Have reduced hours? Severed?Laid off?
19. If so; are you registered with the Social Security Board?
21. Did you resign after March 24th 2020?
Section D: Declaration
I hereby declare that the information given in this claim is true to the best of my knowledge and belief and that I
will not receive or keep any benefit in respect of any period for which I am employed.
25. Claimant's Signature
26. Date Signed (dd/mm/yyyy)
I. This form MUST be accompanied by the relevant documents approved by the Department of Labour;
2. Warning: Any person who knowingly makes any false statement, or false representation for the purpose of
obtaining benefit, will be liable to prosecution.
Date Received
Verification Document Received
For Official Use
Claim Number
Form UB2 (2020)
Please enter your Bank details for payment of your benefit:
24. Name of Financial Institution
23. Account No.22. Name on Account
Select type of Account - Savings
I hereby authorise and request Social Security, to transfer the COVID-19 Relief Benefit payment, to the designated
financial institution for deposit in my account.
If the electronic transmission for this authorisation for any reason results in an overpayment of my benefit payment
due and payable to me, I hereby authorise Social Security to either withhold a sum equal to the overpayment from
my next benefit payment or seek full reimbursement by whatever means is appropriate.
If any action taken by me, without adequate notification to the Social Security Office, results in non-acceptance of
the transfer by the designated financial institution, I understand that the Social Security Office assumes no
responsibility for processing supplemental benefit payments until the funds are returned to the Social Security
Office by the financial institution.
27. Labour Commissioner's Signature
28. Date Signed (dd/mm/yyyy)