Detail

Back to Revised Laws of Saint Lucia (2023)

Schedule

(Regulation 5(1))

NATIONAL INSURANCE CORPORATION
COVID-19 SICKNESS BENEFIT FORM

THIS FORM MUST BE SIGNED AND COMPLETED IN THE CASE OF AN INSURED PERSON (1) IS EMPLOYED BY THE CROWN OR STATUTORY BODY – BY ANY TWO SENIOR OFFICERS INCLUDING THE PERMANENT SECRETARY OR HEAD OF A DEPARTMENT, UNIT OR AGENCY (2) IS EMPLOYED BY AN INDIVIDUAL, PARTNERSHIP OR COMPANY – BY ANY TWO SENIOR EMPLOYEES INCLUDING THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER OR HUMAN RESOURCE MANAGER.

INSTRUCTIONS FOR COMPLETION

This section must be completed by the Employer before the Application is submitted to the NIC.

Employer's Name:

Employer's Registration Number:

Telephone Number:

Email Address:

1. This is to certify that Mr./Mrs./Ms.:

SURNAME

FIRST NAME

2. National Insurance Corporation Number:

Telephone Number:

Address:

3. Employee has been absent from work from:

yyyy

4. Please state exact date employee is
expected to return to work:

yyyy

5. The employee's absence is as a result of:

(i)

Quarantine – He or she is required to abstain from work because he or she may have been exposed to COVID-19 through direct or indirect contact

(ii)

Isolation – He or she is required to abstain from work due to the fact that he or she is manifesting signs and symptoms of COVID-19

(iii)

COVID-19 – He or she is required to abstain from work due to the fact that he or she has been diagnosed with COVID-19.

(iii)

NONE OF THE ABOVE

If COVID-19 is selected please ensure the sick leave form certified by a registered medical practitioner or a medical officer or a person appointed by the Chief Medical Officer is attached to this form

6. Will the employee be receiving his/her full pay for the entire period of absence?

Yes

If “YES”, state the exact period that the employee will be receiving full pay:

From

yyyy

7. Is Applicant still employed?:

Yes

If “NO” please state reason(s):

DECLARATION

I hereby certify that the above-captioned statements are true to the best of my knowledge and belief and I assume full responsibility as to their correctness. I also undertake to notify the National Insurance Corporation as soon as possible of the employee's return to work.

REPRESENTATIVE #1:

SURNAME

FIRST NAME

POSITION:

SIGNATURE:

REPRESENTATIVE #2:

SURNAME

FIRST NAME

POSITION:

SIGNATURE:

EMPLOYER'S STAMP: DATE:

THIS SECTION TO BE COMPLETED BY EMPLOYEE

*Routing Number is necessary if your financial institution is either RBC or RBTT.

EMPLOYEE FINANCIAL INFORMATION

NAME OF FINANCIAL INSTITUTION:

ADDRESS:

ACCOUNT NO.:

CONFIRM ACCOUNT NO.:

BRANCH:

ROUTING NO.:

By providing your account information for the purposes of payment of a benefit to you via direct deposit you agree that the National Insurance Corporation (the Corporation) will rely on the information which you provide for the processing of each payment of the benefit transmitted to you. You are responsible for providing the Corporation with accurate information including; the account number; the name of the Financial Institution; the Branch of the Financial Institution; and any other information determined by the Financial Institution, since payment to you will be processed on said information. I understand that I am solely responsible for any losses arising from the Corporation's reliance on the account information provided, including but not limited to losses associated with funds being incorrectly credited to the wrong beneficiary.

DECLARATION

I hereby certify that the above-captioned statements are true to the best of my knowledge and belief and I assume full responsibility as to their correctness.

EMPLOYEE SIGNATURE: DATE:

Warning: Any person who knowingly makes a false statement or representation for the purpose of obtaining benefit for himself or herself or some other person commits a criminal offence punishable by a fine or imprisonment or both pursuant to the National Insurance Corporation Act.