Labour Sickness

SICKNESS /TEMPORARY DISABLEMENT BENEFIT CLAIM FOR BENEFIT





1______________________________ s/w/d of __________Insurance No. ____________________.. hereby say that I was certified sick/temporarily disabled from __________ a.m./p.m. on the __________ day of________Year________ and I have not been at work since_________ a.m./p.m. on the day of____________200____

I no longer claim to be sick/temporarily disabled from ____________ day of ____________year_________ and I shall/did not take up any work for remuneration prior that day.*

I claim advantage accordingly. I want cash payment at local office/by money order present/last employer __________________ Department ____________Occupation ____________ shift (if any)____________ present address _________

Signature or thumb impression

Local Office _______________

* Strike out if not applicable, and then, before resuming work, a final certificate must be got.