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  • 7 - ForM 14 - Sickness or Temporary Disablement or Maternity Benefit For Sickness

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    Noushad IIA
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    This document contains a form for claiming sickness or temporary disability benefits. The form requires the claimant to provide their insurance number, declare they have not been able to work since the dates on prior medical certificates due to sickness or disability, and state when they are no longer claiming to be sick or disabled. The claimant must sign to request payment of benefits in cash or by money order and provide their present address and local office. Notes on the form warn that making false statements to obtain benefits could lead to prosecution and that the completed form should be promptly sent to the appropriate local office.

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    7 - ForM 14 - Sickness or Temporary Disablement or Maternity Benefit for Sickness

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    This document contains a form for claiming sickness or temporary disability benefits. The form requires the claimant to provide their insurance number, declare they have not been able to work since the dates on prior medical certificates due to sickness or disability, and state when they are no longer claiming to be sick or disabled. The claimant must sign to request payment of benefits in cash or by money order and provide their present address and local office. Notes on the form warn that making false statements to obtain benefits could lead to prosecution and that the completed form should be promptly sent to the appropriate local office.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    19 views1 page

    7 - ForM 14 - Sickness or Temporary Disablement or Maternity Benefit For Sickness

    Uploaded by

    Noushad IIA
    This document contains a form for claiming sickness or temporary disability benefits. The form requires the claimant to provide their insurance number, declare they have not been able to work since the dates on prior medical certificates due to sickness or disability, and state when they are no longer claiming to be sick or disabled. The claimant must sign to request payment of benefits in cash or by money order and provide their present address and local office. Notes on the form warn that making false statements to obtain benefits could lead to prosecution and that the completed form should be promptly sent to the appropriate local office.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    FORM 14

    SICKNESS OR TEMPORARY DISABLEMENT OR

    MATERNITY BENEFIT FOR SICKNESS

    [Regulation 63 ]

    CLAIM FOR BENEFIT

    I,. ....................................son /wife / daughter of. ........................... Insurance No.......... declare that,
    because of sickness / temporary disablement, I have not been at work since the date mentioned in the
    first / last certificate sent to you.

    [ I have not been in receipt of wages on account of leave / holidays. I want on strike during the period of
    certified abstention for which benefit is claimed.]

    I no longer claim to be sick / temporarily disabled, from................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.

    Date......................Signature of thumb impression

    Local Office ..............................

    Present address (if changed) ...........................

    Notes:

    1. Any person who makes a false statement or representation for the purpose of obtaining benefit
    whether for himself or for some other person renders himself liable to prosecution.

    2. This Form should be completed and sent without delay to the appropriate local office.

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