SALARIES RECORD FORM – Sickness Benefit

(To be completed in full by the Employer/ Representative)

Business Name: ARQITEKTON COMPANY LIMITED

Business Address: #13 Garden City Market, Market Square City of Belmopan
Business Phone
Business Registration No.:
Number: 6054814
Business Email Address: Arqitektonbz@gmail.com
Ronny Giovanni Sierra
Name of Insured Person:
Name as per Social Security Card

Insured Person’s Social Security

Number:
0 0 0 1 1 2 2 1 4

1. State if the Insured Person is employed, and indicate last date worked, and time last worked prior to
period of benefit claimed.

a) Presently Employed: Yes: Yes No:

Date Last Worked: 30 05 2023

DD MM YY

5 AM
b) Time Last Worked before illness:
PM

2. State if Insured Person is/was on vacation leave during the period of NO

benefit being claimed: Yes: No:

If Yes, please state vacation period:

To
DD MM YY DD MM YY

3. Kindly insert the Employee’s GROSS salaries for the period listed below. (This information is important to accurately process the
employee’s benefit claim) Double click on box below to fill out date of
Insert the first day of Incapacity > 01-Jun-23 illness/incapacity to automatically calculate the other dates.
Week Commencing Gross Salary
1 22-May-23 $420.00 I certify that the above information is true and correct:
2 15-May-23 $375.00 Axel
3 8-May-23 $340.00
Montero
4 1-May-23 $300.00
5 24-Apr-23 $340.00 Signature of Employer/ Representative
6 17-Apr-23 $380.00 Axel
7 10-Apr-23 $300.00 Montero
8 3-Apr-23 $260.00 Name of Employer/Representative (In Block Letters)
9 27-Mar-23 $420.00
10 20-Mar-23 $340.00
11 13-Mar-23 $420.00 Date: 09 06 2023
12 6-Mar-23 $340.00 DD MM YY
13 27-Feb-23 $420.00

Official Company
SM2/SB (Revised – October 2018)
Stamp
SM2/SB (Revised – October 2018)