UIF Simplicity Illness/Disability Benefit Registration Form First Name Last Name Maiden Name (If Applicable) Address City Postal Code Country Identity Number / Passport Number (For foreigners who contributed to the fund) Current/Previous Occupation (At the time of becoming ill/disabled) Email Home Number Work Number Mobile Number First Name Last Name Email Address Contact Number Relation to you Employer 1 Start Date End Date Employer 2 Start Date End Date Employer 3 Start Date End Date Employer 4 Start Date End Date Employer 5 Start Date End Date Monthly hours worked I was declared unfit to work, from date I was declared unfit to work, until date Reason for being unfit for work? Declared unfit for work by whom? Declared unfit due to illness or disability?? Please Select Illness Disability Have you been medically boarded by a medical practitioner? Please Select Yes No Have you claimed from the UIF before? If so, in which year and what kind of UIF claim was it? Have you used another UIF claim Agency before? If so, please supply date. How long have you been contributing to the UIF? What is your current monthly gross salary before deduction at time of becoming unfit? How did you come to hear about us? Through a friend Google Bing Facebook Instagram Hospital UIF Simplicity agent Bernice van der Berg Other If you selected other, please specify. Send
