Form B.58 - Claim For Retirement Benefit Page 2
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1
2PLACES OF EMPLOYMENT SINCE OCTOBER, 1974
In addition to your current or last employer (stated on front), we’d like to know the details of your past
employment history. This would help greatly in ensuring that your claim is processed speedily and cor-
rectly. (Use blank sheet to list additional employers if needed)
#1
COMPANY: _____________________________________ EMPLOYEE #:________DEPT. #_______
OWNER: ________________________________ CONTACT PERSON:______________________________
STREET ADDRESS: ________________________________________________________________________
MAILING ADDRESS:______________________________ PHONE CONTACT:______________________
NATURE OF YOUR WORK:____________________________________ EARNINGS:_________________
EMPLOYMENT: When Started:_________________________ When Left:___________________________
#2
COMPANY: _____________________________________ EMPLOYEE #:________DEPT. #_______
OWNER: ________________________________ CONTACT PERSON:______________________________
STREET ADDRESS: ________________________________________________________________________
MAILING ADDRESS:______________________________ PHONE CONTACT:______________________
NATURE OF YOUR WORK:____________________________________ EARNINGS:_________________
EMPLOYMENT: When Started:_________________________ When Left:___________________________
#3
COMPANY: _____________________________________ EMPLOYEE #:________DEPT. #_______
OWNER: ________________________________ CONTACT PERSON:______________________________
STREET ADDRESS: ________________________________________________________________________
MAILING ADDRESS:______________________________ PHONE CONTACT:______________________
NATURE OF YOUR WORK:____________________________________ EARNINGS:_________________
EMPLOYMENT: When Started:_________________________ When Left:___________________________
#4
COMPANY: _____________________________________ EMPLOYEE #:________DEPT. #_______
OWNER: ________________________________ CONTACT PERSON:______________________________
STREET ADDRESS: ________________________________________________________________________
MAILING ADDRESS:______________________________ PHONE CONTACT:______________________
NATURE OF YOUR WORK:____________________________________ EARNINGS:_________________
EMPLOYMENT: When Started:_________________________ When Left:___________________________
#5
COMPANY: _____________________________________ EMPLOYEE #:________DEPT. #_______
OWNER: ________________________________ CONTACT PERSON:______________________________
STREET ADDRESS: ________________________________________________________________________
MAILING ADDRESS:______________________________ PHONE CONTACT:______________________
NATURE OF YOUR WORK:____________________________________ EARNINGS:_________________
EMPLOYMENT: When Started:_________________________ When Left:___________________________
PLEASE NOTE:
Any person who, for the purpose of obtaining a benefit under the National Insurance Act, either for himself or
some other person, makes any false statement or false representation, or produces any false documents, etc,
shall be liable to a fine not exceeding $2,500, or to imprisonment for up to twelve months, or both.
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