Form Ui-2.3 - Application For Maternity Benefits

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UI-2.3
UNEMPLOYMENT INSURANCE ACT 63 OF 2001
APPLICATION FOR MATERNITY BENEFITS IN TERMS OF SECTION 25(1) - Read with Regulation 5(1) and 5(4)
13 Digit Bar-Coded Identity Document/Passport Number
Date of Birth (dd/mm/yy)
Gender
Female
0
First Names
Surname
Postal Address
Code /Telephone No
Code
Residential Address
Cell No
Code
Occupation
Occ. Code
E-Mail Address
Fax Number
Method of Payment
Use the UI-2.8 form for Banking Details
PAYPOINT
CHEQUE
BANK TRANSFER
OTHER
Details of previous application
a) Name and ID No under which you applied:
b)
Date of Application: ____/___/_____
c)
Office of application:
ARE YOU STILL EMPLOYED
YES
NO
MEDICAL CERTIFICATE (to be completed by a medical practitioner or registered
SOURCES OF OTHER INCOME (mark X were applicable)
midwife)
NB:
IF YOU ARE STILL EMPLOYED, FORM UI-2.7 MUST ALSO BE
1.
Monthly Pension from State (Excluding Disability grant)
COMPLETED.
2.
Benefit from Compensation Fund for temporary or total
I, ___________________________________________am a qualified ___________________ .
disablement
DATE OF COMMENCEMENT OF MATERNITY LEAVE: _____/_____/______
Qualifications _____________________________. My practice number is ________________..
3.
Benefits from an Unemployment Fund established by a
bargaining or statutory council
IF YOU HAVE RETURNED TO WORK, STATE DATE: _____/_____/______
I confirm that____________________ is under my treatment and is pregnant. The expected
4.
NONE
IMPORTANT: READ THIS SECTION BELOW:
If applicable mark X on 1-4:
due date of birth is _________________.
OR
When did you begin to receive this income? ____________________
If your application is successful the claims officer will authorise
I confirm that ________________________ gave birth on _________. \ The baby was stillborn
the payment of benefits. You must also inform the claims officer
as soon as you resume employment
I declare that the above
Do you continue to receive this income? _____________
on ______________________ \ the patient had a miscarriage on ______________________..
information is true and correct. I understand that it is an offence
to make a false statement.
Signature __________________ Date __________ Tel No. _______________
If you no longer receive this income when did it come to an end? _______
Address ___________________________________________________________________
SIGNATURE OF APPLICANT: ______________________________ DATE: ________________
FOR OFFICIAL USE ONLY
OFFICE STAMP
Signature of Official
DOCUMENTS/INFORMATION SUBMITTED
Claim approved from: ______________________
1.
UI-19 (If Applicable)
8.
Telephonic Verification
Application refused in terms of: ______________________
2.
Certified Copy of ID
Contact Person
REMUNERATION/SALARY
Claims officer (Please Print): _________________________________________
3.
Payslips
Gross pay
Payment Frequency
4.
Proof of banking details - UI-2.8
(before deductions)
(PW or PM)
Signature: ________________________________
5.
UI-2.7 (If Applicable)
Designation:
6.
SARS Number: ____________________
Tel. No.:
Date: _______________
7.
Other (Specify) ____________________

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