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labour

UI-3

Department:

Labour

REPUBLIC OF SOUTH AFRICA

UNEMPLOYMENT INSURANCE ACT 63 OF 2001

APPLICATION FOR CONTINUATION OF PAYMENT FOR ILLNESS BENEFITS IN TERMS OF REGULATION 4(4)

FORM MUST BE COMPLETED ON OR AFTER

ID NO.

1. Surname:

2. Previous surname: (Only if it changed since your last declaration).

3. First names:

d I

n e

i t

y t

u n

e b

: r

. 5

Telephone number:

s o

l a t

d a

r d

s e

: s

7. Residential address: (If different from postal address)

Postal code

8. Date returned to work:

_____/_______/_______________

NB: IF YOUR BANKING DETAILS HAVE CHANGED, FORM UI-2.8 MUST BE COMPLETED

CONFIRM YOUR BANKING DETAILS (This portion to be completed by applicant and is not necessary to be completed by Financial Institute)

Name of account holder ______________________________________________

Name of Financial Institution __________________________________________

r B

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h c

o c

e d

c c

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I declare, except as stated in item 8, that I have not worked since the date of my application for illness benefits and have not been entitled to

my normal remuneration as declared by my employer on the prescribed form UI-2.7 submitted with my application form.

I declare that I am still incapacitated and unable to perform work. I declare further that the information provided is true and correct.

I am aware that it is an offence to willfully make a false statement.

________________________

______/_____/_______

g i

a n

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f o

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MEDICAL CERTIFICATE

(To be completed by a registered practitioner in terms Section 20(1)(c) of Act 63 of 2001)

I, _______________________________________________________ am a qualified ______________________________________________

qualifications ________________. My Registration number is __________________ OR My Practise number is: ___________________________.

I confirm that _____________________________________________________________________________________________________ has been

under my treatment

from _______________ to ____________________ and is suffering from___________________________________________________________

This patient was not capable of performing work from ____________________________________ to ____________________________________

Signature ________________________________

Date __________________________________ Tel No. _____________________________

Address ________________________________________________________________________________________________________________

NB!

THIS FORM MUST BE SUBMITTED TO YOUR NEAREST DEPARTMENT OF LABOUR OFFICE..

NO POST DATED FORMS WILL BE ACCEPTED OR PROCESSED.

IN THE EVENT OF YOU RESUMING EMPLOYMENT YOU ARE REQUIRED TO INFORM THE DEPARTMENT OF LABOUR

OFFICES IMMEDIATELY AND TO REQUEST THE NEW EMPLOYER TO SUBMIT A DECLARATION.

Form Ui-3 - Application For Continuation Of Payment For Illness Benefits In Terms Of Regulation - Department Of Labour, Republic Of South Africa

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