Sickness or Temporary Disablement Benefit Claim for Benefit
| Updated at | March 2010 |
I, ……………....................., s/w/d of ………………………… 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 claim benefit accordingly. I desire payment in cash at local office/by money order. Signature or thumb impression...
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