Dependants' Benefit Labour Act 1383 - Legal Draft
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Maternity Benefit
Claim Form
I
.............................
Insurance No
...............
wife of/daughter of
........................
here claim maternity benefit with effect from the
.............
day of
20......Claim Form
I hereby declare that I have ceased/shall cease to work for remuneration with effect from that date.
Present/last employer .................
Department, shift and occupation ..........
Present address ...................
Date ....................
Signature or thumb impression