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 Administration Branch
4th Floor
Northern Ireland Policing Board
31 Clarendon Dock
Belfast
BT1 3BG
 

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;

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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) (PDF 293 KB)

    1.2 Application Declaration Form & Privacy Notice (APP-DEC) (PDF 391 KB)

    1.3 Medical Report Disclosure Form (MED-DISC) (PDF 318 KB)

     

    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) (PDF 246 KB)

    2.2 Application Declaration Form & Privacy Notice (APP-DEC) (PDF 391 KB)

    2.3 Medical Report Disclosure Form (MED-DISC) (PDF 318 KB)

     

    3. Retrospective Ill Health Retirement Pension

    If you are a former RUC or PSNI officer and wish to apply for a Retrospective Ill Health Retirement Pension please complete the following three forms and return them to the Board for consideration;

    3.1 Retrospective Ill Health Retirement Application Form (R-IHR) (PDF 179 KB)

    3.2 Application Declaration Form & Privacy Notice (APP-DEC) (PDF 391 KB)

    3.3 Medical Report Disclosure Form (MED-DISC) (PDF 318 KB)

     

    4. 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;

    4.1 Deferred Pension Application Form (DEF-PEN) (PDF 179 KB)

    4.2 Application Declaration Form & Privacy Notice (APP-DEC) (PDF 391 KB)

    4.3 Medical Report Disclosure Form (MED-DISC) (PDF 318 KB)

     

    5. 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;

    5.1 Adult Survivor Award Application Form (AD-SUR) (PDF 181 KB)

    5.2 Application Declaration Form & Privacy Notice (APP-DEC) (PDF 391 KB)

    5.3 Medical Report Disclosure Form (MED-DISC) (PDF 318 KB)

     

    6. Appeals

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

    6.1 Appeal Application Form – 1988 IHR only (PDF 171 KB)

    6.2 Appeal Application Form – 2006 IHR only (PDF 171 KB)

    6.3 Appeal Application Form – 2015 IHR only (PDF 171 KB)

    6.4 Appeal Application Form – Retrospective IOD only (PDF 171 KB)

    6.5 Appeal Application Form – 1988 IHR and IOD (PDF 174 KB)

    6.6 Appeal Application Form – 2006 IHR and IOD (PDF 173 KB)

    6.7 Appeal Application Form – 2015 IHR and IOD (PDF 173 KB)