Labour Sickness Temporary Disablement Benefit Claim For Benefit

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____________20________ 

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.