SICKNESS /TEMPORARY DISABLEMENT BENEFIT CLAIM FOR BENEFIT  [CD1] 

 


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............20........ 

 

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.

 [CD1]SICKNESS /TEMPORARY DISABLEMENT BENEFIT CLAIM FOR BENEFIT