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    13 Digit Bar-Coded Identity Document/Passport Number Date of Birth (Dd/mm/yy)

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    THE CONTINENTAL EVENTS
    This document appears to be an application form for maternity benefits from South Africa's Unemployment Insurance Fund. The form requests information such as the applicant's identity number, contact details, occupation, education level, and previous applications. It includes a medical certificate section to be completed by a medical practitioner confirming the pregnancy and expected due date. The applicant agrees that benefits will be authorized if approved, and to refund any overpayments. Officials review and either approve or refuse the application.

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    13 Digit Bar-Coded Identity Document/Passport Number Date of Birth (Dd/mm/yy)

    Uploaded by

    THE CONTINENTAL EVENTS
    22 views1 page
    This document appears to be an application form for maternity benefits from South Africa's Unemployment Insurance Fund. The form requests information such as the applicant's identity number, contact details, occupation, education level, and previous applications. It includes a medical certificate section to be completed by a medical practitioner confirming the pregnancy and expected due date. The applicant agrees that benefits will be authorized if approved, and to refund any overpayments. Officials review and either approve or refuse the application.

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    This document appears to be an application form for maternity benefits from South Africa's Unemployment Insurance Fund. The form requests information such as the applicant's identity number, contact details, occupation, education level, and previous applications. It includes a medical certificate section to be completed by a medical practitioner confirming the pregnancy and expected due date. The applicant agrees that benefits will be authorized if approved, and to refund any overpayments. Officials review and either approve or refuse the application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    22 views1 page

    13 Digit Bar-Coded Identity Document/Passport Number Date of Birth (Dd/mm/yy)

    Uploaded by

    THE CONTINENTAL EVENTS
    This document appears to be an application form for maternity benefits from South Africa's Unemployment Insurance Fund. The form requests information such as the applicant's identity number, contact details, occupation, education level, and previous applications. It includes a medical certificate section to be completed by a medical practitioner confirming the pregnancy and expected due date. The applicant agrees that benefits will be authorized if approved, and to refund any overpayments. Officials review and either approve or refuse the application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    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)

    First Names: Surname:

    Postal address: Code: Code /Telephone No: Residential address: Code: Code /Telephone No:

    Occupation: E-mail: Fax:

    Education:
    SPECIAL SCHOOL CERT. GRADE 8-9 GRADE 12

    BELOW GRADE 8 GRADE 10 - 11 ABOVE GRADE 12


    Use the UI-2.8 form for Banking Details
    Details of previous application
    a) Name and ID / Passport No under which you applied:_________________________________________________________________________________________________________________________________

    ARE YOU STILL EMPLOYED Yes No


    MEDICAL CERTIFICATE (to be completed by a medical practitioner or registered midwife)
    NB: IF YOU ARE STILL EMPLOYED, FORM UI-2.7 MUST ALSO BE COMPLETED.
    I, _____________________________am a qualified ___________________. Qualifications _____________________
    IF YOU HAVE RETURNED TO WORK, STATE DATE:____________ / _____________ /__________________
    My registration number is __________________________. I confirm that____________________ is under my treatment
    and is pregnant.
    IMPORTANT: READ THIS SECTION BELOW:
    The expected due date of birth is _________________.OR I confirm that ___________________ gave birth / stillborn /
    In the event of my application being successful, the Claims Officer will authorise the payment of benefits. I also undertake miscarriage on___________________.
    to inform the Claims Officer as soon as I am re-employed and understand that failure to do so will constitute fraud. Doctor’s stamp
    Signature __________________ Date _____________ Tel No. ___________________
    In the event of an overpayment occurring as a result of this application I undertake that I will refund the full amount to the
    Fund. Address_____________________________________

    I declare that the above information is true and correct.

    SIGNATURE OF APPLICANT / PROXY SIGNATURE OF OFFICIAL Claim approved from: ___________________ Office Stamp

    Application refused in terms of_______________

    Date____________________ COMPLETE YES NO Claims officer (Please Print): ________________

    Signature: ___________________Date: ____________

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