Sickness or Temporary Disablement Benefit Claim for Benefit

Sickness or Temporary Disablement Benefit Claim for Benefit

I ………………….…………………. s/w/d of  ………………..………….……………….

Insurance No.  ………………………   hereby state that I was certified sick/

temporarily disabled from ………… a.m./p.m. on the ………… day of ……… 19……… and I have not been at work since ………… a.m./p.m. on the day of ………… 19……… .

I no longer claim to be sick/temporarily disabled from ………… day of ………… 19……… and I shall/did not take up any work for remuneration before that day.*

I claim benefit accordingly. I desire payment in cash 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 obtained.

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