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…………200…

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.