Sickness Or Temporary Disablement Benefit Claim For Benefit Labour Act 1386 - Legal Draft
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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
............
If a notice of the accident had
not been given to the employer, state briefly on a separate paper how the
accident happened.
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.
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
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.
Present Address