Maternity Benefit Statement Of Earnings Page 2
ADVERTISEMENT
1
2FOR OFFICIAL USE
1.
DOCUMENTS SUBMITTED WITH CLAIM
2.
DECISION
1. .....................................................................
ALLOWED
2. .....................................................................
DISALLOWED
3. .....................................................................
(Tick appropriate box)
IF ALLOWED
3.
CALCULATION OF RATE
MONTH
SALARY ($)
(To be completed if salary is paid by employer)
Actual
Insurable
(a) Average monthly/weekly earnings $……….…...
1.
(b) 70% avg. mthly/wkly insurable earnings $……..
2.
(c) Salary/wage paid
$…………...
Total
(d) Total item b) and c)
$……………
Avg. Monthly
(e) Item d) – item a)
$……………
(enter 0 if answer is negative)
WEEK
WAGES ($)
(f) Rate of Benefit (Item 6 - Item e)
Actual
Insurable
1.
2.
3.
$
Per month/week
4.
5.
6.
7.
8.
Total
Avg. Weekly
Rate per month/week – 26/6
$
Rate = 0.7 x wkly/mthly ins. earnings
Per day
4.
PARTICULARS OF PAYMENT
Date of Commencement
Stop Date
Review Date
Payment Made:
FROM
TO
AMT. PAID
Prepare
Date
Checked
Date
Auth.
Date
B.P.
Date
$
C
d By
By
By
V
No.
1.
2.
3.
4.
5.
IF DISALLOWED
1.
Date claim Disallowed
2.
Reason for Disallowance .......................................................................................................................................…...
3.
Date claimant notified
6.
IF DISQUALIFIED
7.
NOTIFICATION
Period of Disqualification
Department/Section
From
_______________
To ________________
Form No.
Reason for Disqualification .................................................
Date Sent
.............................................................................................
Signature
Remark
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal