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……………20….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 20………….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.

ACCIDENT CASE ONLY
Date, time and place of accident…………If a notice of the accident had
not been given to the employer, state briefly on a separate paper how the accident happened.
Signature or thumb impression
SICKNESS OR TEMPORARY DISABLEMENT BENEFIT CLAIM FOR BENEFIT
I, 	, s/w/d of	 Insurance
No	  declare that because of sickness/temporary
disablement, I have not been at work since the date of last/first certificate sent to you.
I claim benefit accordingly. I desire payment in cash at local office/by money order.
Signature or thumb impression
Date		Local office	
Present Address	
CLAIM FOR PERMANENT DISABLEMENT BENEFIT
I,	, s/w/d of	Insurance
No	having been declared as permanently disabled by
the Medical Board/Appeal Tribunal claim permanent disablement benefit
accordingly for the period from	to 4	
The amount due may be paid to me by money order/in cash at local office.
Date		Signature or thumb impression
Present Address	
Another Form
I, 	 s/w/d of	
Insurance No	declare that,  because of sickness/temporary
disablement, I have not been at work since the date of last/first certificate sent to you.
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.
Signature or thumb impression
Date		Local office	
Present Address