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Click ‘Get Form’ to open it in the editor.
Begin by filling in your personal details. Enter your surname, first name(s), and title (MR, MRS, MISS, MS).
Provide the date you last worked before your sickness began and the time you finished work on that date using the 24-hour format.
Indicate whether your sickness was caused by an accident at work or an industrial disease by selecting 'Yes' or 'No'. If 'Yes', consider seeking information about Industrial Injuries Disablement Benefit.
Fill in your National Insurance number, date of birth, and clock or payroll number.
In the section about your sickness, provide brief details along with the start and end dates of your sickness. If unsure about the end date, leave it blank.
Finally, sign the form electronically to confirm its accuracy before submitting it to your employer.
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