This form must be submitted at least days before the date on which you your illness to commence.

NAME: ............................................. STAFF NO: ..................................……..

DEPARTMENT: ............................... POSITION HELD: .........................……

NATURE OF ILLNESS: .........................................................................……

DATE ON WHICH YOU WISH ILLNESS TO COMMENCE: ............................

Applications to suffer from Pregnancy must be submitted 12 months before and must be accompanied by Form no. (VS.36/24/98).

CONSENT OF HUSBAND / WIFE

HAVE YOU EVER APPLIED TO HAVE THIS ILLNESS BEFORE: ...................

IF SO, PLEASE GIVE DATE: .......................................

DO YOU WISH THIS ILLNESS TO BE SLIGHT / SEVERE / CRIPPLING / FATAL.

IF ILLNESS IS FATAL DO YOU WISH TO BE CONSIDERED A PERMANENT DISABILITY:

YES / NO

(Applicants Wishing to Suffer a fatal illness should indicate whether they wish to be represented at the funeral / cremation)

DO YOU WISH TO SUFFER THIS ILLNESS AT HOME / COSTA BRAVA / JAMAICA / HOSPITAL / WITH LOVER: ......................................................................................………………………….

DO YOU WISH THIS ILLNESS TO BE CONTAGIOUS. YES / NO

IF YES, PLEASE STATE HOW MANY PEOPLE YOU WISH TO INFECT: .…

HAVE YOU EVER BEEN REFUSED TO SUFFER FROM AN ILLNESS:

YES / NO

IF YES, PLEASE GIVE DETAILS: ........................................................................

DO YOU WISH YOUR WIFE / HUSBAND TO BE INFORMED OF YOUR ILLNESS IF SHE/HE CONTACTS THE COMPANY REGARDING YOUR WHEREABOUTS:

............................................................................................................…………...

I, the under signed, declare that to the best of my knowledge the answers given above are true and accurate.

SIGNED: .................................................... DATE: ............................................…

Under NO CIRCUMSTANCES Will any employee be permitted to suffer more than one fatal illness.