Form Ui-2.2 - Application For Illness Benefits
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1UI-2.2
UNEMPLOYMENT INSURANCE ACT 63 OF 2001
APPLICATION FOR ILLNESS BENEFITS IN TERMS OF SECTION 22(1) - Read with Regulations 4(1), 4(5) and 4(7)
13 Digit Bar-Coded Identity Document/Passport Number
Date of Birth (dd/mm/yy)
Gender
Male
5
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
SOURCES OF OTHER INCOME (mark X were applicable)
MEDICAL CERTIFICATE (To be completed by an authorised practitioner in terms of section
NB:
IF YOU ARE STILL EMPLOYED, FORM UI 2.7 MUST ALSO BE
Monthly Pension from State (Excluding Disability grant)
1.
20(1)(c) of the UI Act 63 of 2001.
COMPLETED.
2.
Benefit from Compensation Fund for temporary or total disablement
DATE OF COMMENCEMENT OF SICK LEAVE: _____/_____/______
3.
Benefits from an Unemployment Fund established by a bargaining or
I, ________________________________am a qualified _______________________________.
statutory council
Qualifications _____________________________. My practice number is ________________.
4.
None
IF YOU HAVE RETURNED TO WORK, STATE DATE: _____/_____/______
I confirm that_______________________________________ has been under my treatment
If applicable mark X on 1-4:
IMPORTANT: READ THIS SECTION BELOW:
from ____________ to __________ and is suffering from ______________________________.
When did you begin to receive this income? ________________________
This patient was not capable of performing work from ________________ to ____________ .
If your application is successful the claims officer will
authorise the payment of benefits. You must inform the
If the nature of the illness is described in this medical certificate in uncertain terms or as “disease
Do you continue to receive this income? ________________________
– entity” or “symptom complex”, please furnish a clinical report describing the symptoms and
claims officer as soon as you resume work. I declare that
nature of the complaint.
the above information is true and correct. I understand
If you no longer receive this income when did it come to an end?
that it is an offence to make a false statement.
Signature __________________ Date __________ Tel No. _______________
__________________________________________________________
Address ___________________________________________
SIGNATURE OF APPLICANT: ______________________________ DATE: ________________
OFFICE STAMP
FOR OFFICIAL USE ONLY
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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