Application Forms

This page contains a range of forms, relating to various awards and/or benefits which can be considered and conferred by the Policing Board.

These forms can be completed by former officers and adult survivors. These forms can also be completed by the appointed representative of a former officer and/or adult survivor, provided the relevant authority forms have been completed.

An applicant may wish to forward additional information and/or documentary evidence to support an application. In light of this, and for security purposes, forms should be completed in hard copy format only and returned to the Policing Board with any supplementary information. Application forms and any supplementary information should be returned to the Policing Board by post or hand delivery to the following address;

Police Pensions and Injuries Benefits Branch
Northern Ireland Policing Board
James House, Block D
2 – 4 Cromac Avenue
The Gasworks
Belfast
BT7 2JA
 

Please be advised, we cannot accept forms via fax or email.

Privacy Notices

The Northern Ireland Policing Board is committed to protecting the information supplied to it by applicants and other parties, as well as adhering to all relevant data protection legislation. Please see our Privacy Notices below for further information;

Application Forms

1. Retrospective Injury on Duty Award

If you are a former RUC or PSNI officer and wish to apply for a Retrospective Injury on Duty award please complete the following three forms and return them to the Board for consideration;

1.1 Retrospective Injury on Duty Award Application Form (R-IOD)

1.2 Application Declaration Form & Privacy Notice (APP-DEC)

1.3 Medical Report Disclosure Form (MED-DISC)

2. Reassessment of an Injury on Duty award

If you believe that the degree of your disablement has altered since the date on which you were granted an Injury on Duty award you can request that you case be reassessed by completing the following three forms and returning them to the Board for consideration;

2.1 Requested Reassessment Application Form (REQ-RE)

2.2 Application Declaration Form & Privacy Notice (APP-DEC)

2.3 Medical Report Disclosure Form (MED-DISC)

3. Deferred Pension – Paid early due to ill-health

If you are a former RUC or PSNI officer and wish to apply to have your Deferred Pension paid early due to ill-health please complete the following three forms and return them to the Board for consideration;

3.1 Deferred Pension Application Form (DEF-PEN)

3.2 Application Declaration Form & Privacy Notice (APP-DEC)

3.3 Medical Report Disclosure Form (MED-DISC)

4. Adult Survivor Special/Augmented Award

If you are a widow, widower civil partner or adult partner of a deceased PSNI/PSNI Reserve Officer (or former RUC/RUC Reserve Officer) and wish to apply for an Adult Survivor Award, please complete the following forms and return them to the Board;

4.1 Adult Survivor Award Application Form (AD-SUR)

4.2 Application Declaration Form & Privacy Notice (APP-DEC)

4.3 Medical Report Disclosure Form (MED-DISC)

5. Appeals

If you are a serving PSNI officer or a former RUC/PSNI officer and wish to appeal the Selected Medical Practitioner’s decision to refuse an award for Ill Health Retirement and/or an Injury on Duty award please complete the following appeal form and return this to the Board for consideration;

Application Form – Appeal of Decision of Selected Medical Practitioner