To submit this form, you can either take it in person to the Department of Social Insurance, Ground Floor, Government Administration Building, 30 Parliament Street, Hamilton HM 12, Bermuda, or mail it to the same address. You may also submit it via email to sibenefits@gov.bm or fax to 441-295-9467. Ensure all sections are completed, and attach required documents such as a certified copy of your birth certificate, photo ID, or valid passport, and proof of banking details. For queries, call 294-9242 ext 1129 or email sibenefits@gov.bm.

Ensure to submit the form within 13 weeks of becoming eligible in 2024 and 2025.

The purpose of this form is to facilitate the application process for contributory pensions and gratuities in Bermuda. By providing necessary personal and employment details, the form helps the Department of Social Insurance to assess eligibility and process benefits efficiently. Timely submission of this form ensures that applicants can receive their due benefits without unnecessary delays.

• 1. Surname: Enter your last name as it appears on your official documents.
• 2. First Name: Enter your first name as it appears on your official documents.
• 3. Maiden Name (or other surname at date of birth): If applicable, provide your maiden name or any other surname at your date of birth.
• 4. Permanent Address: Provide your permanent residential address.
• 5. Mailing Address: If different from your permanent address, provide your mailing address.
• 6. Telephone Number(s): Enter your contact telephone number(s).
• 7. Email Address: Provide your email address for correspondence.
• 8. Date and Place of Birth: Enter your date and place of birth and submit a certified copy of your birth certificate and photo ID or passport.
• 9. UK National Insurance No.: If applicable, provide your UK National Insurance Number.
• 10. Bank Name: Provide the name of your bank and submit proof of banking details.
• 11. Account Number: Enter your bank account number.
• 12. IBAN Number/Routing Number: If applicable, provide your IBAN or routing number.
• 13. Sort Code: If applicable, provide your bank sort code.
• 14. Receipt of Social Insurance Benefit: Indicate if you are receiving any social insurance benefit and specify the type if applicable.
• 15. Date of Last Employment (In Bermuda): Provide the date and place of your last employment in Bermuda.
• 16. Retirement Date: If retired, state the date on which you ceased to be gainfully employed.
• 17. Employment History: List your employment history with details of employer, time period, and full time or part time status.
• 18. Spouse's Name: Enter the name of your spouse.
• 19. Spouse's Social Insurance Number: Provide your spouse's social insurance number.
• 20. Spouse's Date of Birth: Enter the date and place of birth of your spouse.
• 21. Declaration: Applicant's declaration that all provided information is true, along with their usual signature or mark if unable to write.
• 22. Witness to Signature: A witness to the applicant's signature, providing their name, signature, address, and date.

Failing to submit this form may result in the loss of pension benefits. It is crucial to complete and submit the form within the required timeframe.

• Loss of Benefit: Delay in submitting the form may result in the loss of pension benefits.
• Delayed Pension Payment: An incomplete application may cause delays in processing and payment of pension benefits.

• 1. Retirement Age: You should use this form when you are over the retirement age of 65.
• 2. Eligibility for Benefit: Use this form when you meet the contribution conditions for the pension.