Sick Pay Claim Form printable pdf download

UFCW/WESTFAIR BENEFIT PLAN

SICK PAY CLAIM FORM

IMPORTANT:

To be accepted, your claim must be submitted to the Administrator no later than 45 days after your

first day off due to illness or injury. Payment will not be made for partial shift absences. Please answer all questions

and sign the form. This claim will be returned to you if it is incomplete or contains errors.

Any Employee making a false claim will be required to repay any monies paid by the Trust Fund and may

have future eligibility discontinued by the Trustees.

Please see reverse side for instructions on completion and Certification and Consent

SECTION 1 - MEMBER’S STATEMENT

Member’s Name __________________________________________________ SIN _________________________

(First)

(Last)

Address ______________________________________________________________________________________

(Number and Street)

(City)

(Province)

(Postal Code)

Phone Number _______________________________

I hereby certify that I was absent from employment due to (please “X” one) :

 illness

 injury

on the following scheduled working day(s):

Date

Hrs. Scheduled

Hrs. Worked

Sun

Mon

Tues

Wed

Thurs

Fri

Sat

If an injury was sustained, describe when, where and how injury occurred (include police report number and MPI

claim number, if applicable) __________________________________________________________________________

______________________________________________________________________________________________

 Yes

 No

Is the illness/injury work related?

 Yes

 No

If “Yes” has a claim been made to Worker’s Compensation?

I CERTIFY THAT I AM AWARE OF AND HAVE READ the “Certification and Consent” on the reverse side of this form.

__________________________________

Signature of Member

Date

SECTION 2 - EMPLOYER VERIFICATION

Store Number

_________________________

Hourly Wage Rate

__________________

I hereby verify that the above-named Employee was absent from employment due to illness or injury on the following

scheduled working day(s):

Date

Hrs. Scheduled

Hrs. Worked

Sun

Mon

Tues

Wed

Thurs

Fri

Sat

_____________________

____________________________________________

Management’s Signature

Date

Please complete and return this form to:

UFCW/WESTFAIR BENEFIT PLAN

3rd Floor, 880 Portage Avenue Winnipeg, Manitoba R3G 0P1

Phone: 204-982-6087 (in Winnipeg) 1-877-982-6087 (outside Winnipeg)

Sick Pay 2013

Sick Pay Claim Form

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