Form Ui-3 - Application For Continuation Of Payment For Illness Benefits

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UI-3
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 previous application)
3. First names:
4. Identity number:
5. Telephone number:
6. Postal address:
7. Residential address: (If different from postal address)
Postal code
8. Date returned to work:
_____/_______/_______________
9. Kindly state whether you are in receipt of income from other sources.
Tick () where applicable.
1. Monthly Pension from State (Excluding Disability grant)
I declare, except as stated in item 8, that I have not worked
2.
Benefit from Compensation Fund for temporary or total
since the date of my application for illness benefits and have
disablement
not been entitled to my normal remuneration/or will receive a
Benefits from an Unemployment Fund established by a
3.
portion of my normal remuneration as declared by my
bargaining or statutory council
employer on prescribed form UI-2.7 submitted with my
NONE
application form.
4.
If any of above is applicable complete the following questions:
I furthermore declare that the information given is true and
When did you begin to receive this income? ___________________
correct. I am aware that it is an offence to willfully make a
false statement.
Do you continue to receive this income? ______________________
If you no longer receive this income when did it come to an end?
_______________________
________________________
______/_____/_______
Signature of applicant
Date
NB: IF YOUR BANKING DETAILS HAVE CHANGED, FORM UI-2.8 MUST BE COMPLETED
MEDICAL CERTIFICATE
(To be completed by an authorised practitioner in terms Section 20(1)(c) of Act 63 of 2001)
I, _______________________________________________________ am a qualified ______________________________________________
qualifications _______________________________________. My practice 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 ________________________________________________________________________________________________________________

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