Claim and Notes for Bereavement Payment form (FA008M)

Use this form if you are the birth mother or partner of the birth mother and you want to claim payments for a child who was stillborn or who has recently died.

Download and complete the Claim and Notes for Bereavement Payment form.

This form contains 2 sections - notes and claim form.

In cases of stillbirth and infant death, your maternity hospital or registered midwife will provide you with a different version of this form, which will include a declaration for your attending doctor or midwife to complete.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please use self service, request someone to deal with us on your behalf, or contact us. We can help you access, complete and submit them.

Page last updated: 14 September 2020