Sc Ins5140 PDF Details

The SC INS5140 form is an important document for businesses in South Carolina. This form is used to register a new business in the state, and it must be filed with the Secretary of State's office. The process of registering a business can be complicated, but the SC INS5140 form makes it easy to get started. This guide will walk you through the process of filling out and filing the SC INS5140 form.

We have gathered some interesting information about the sc ins5140. You will have the approximate time you will need to complete the form plus some additional details.

QuestionAnswer
Form NameSc Ins5140
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesins5140 form, medical certificate, sc ins5140, medical certificate sc ins5140

Form Preview Example

Service

 

Canada

MEDICAL CERTIFICATE

 

PROTECTED WHEN COMPLETED - B

FOR EMPLOYMENT INSURANCE SICKNESS BENEFITS

SECTION 1 THE CLAIMANT MUST COMPLETE THIS SECTION TO AUTHORIZE THE RELEASE OF THE INFORMATION REQUESTED IN SECTION (2) TO THE INSURER.

Social Insurance Number

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

M

D

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

First Name

Initials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Postal Address

 

 

 

 

 

 

 

Number and Street, Concession, Other

 

Apt. No.

 

Area Code Telephone Number

 

 

 

 

 

City or Town

 

 

 

 

 

 

 

 

Province / Territory

Postal Code

 

 

 

 

 

 

 

I hereby authorize the release of all information related to my present illness and/or my pregnancy to the Insurer and to the insurer's medical examiner. Any charge for providing this information is my personal responsibility.

Signature of claimant, representative or next of kin

Y M D

THE INFORMATION YOU PROVIDE ON THIS FORM IS COLLECTED UNDER THE AUTHORITY OF THE E.I. ACT AND WILL BE USED TO DETERMINE YOUR ELIGIBILITY FOR INCOME BENEFITS. THIS INFORMATION WILL BE RETAINED IN THE PERSONAL INFORMATION BANK ENTITLED "E.I. CLAIM FILE" (REGISTRATION NUMBER ESDC PPU 150). INSTRUCTIONS FOR ACCESSING YOUR PERSONAL INFORMATION ARE PROVIDED IN INFO SOURCE, A COPY OF WHICH IS AVAILABLE AT SERVICE CANADA CENTRES. YOUR PERSONAL INFORMATION IS PROTECTED AND ACCESSIBLE UNDER THE PRIVACY ACT.

SECTION 2 MUST BE COMPLETED BY A MEDICAL DOCTOR OR OTHER HEALTH PRACTITIONER ACCEPTABLE TO THE COMMISSION

PREGNANCY

What is the expected date of confinement?

What was the actual date of confinement?

Y M D

Y M D

INCAPACITY

Date on which the above patient became unable to work due to their medical condition.

Y M D

In my opinion, the above patient is incapable of working until:

COMMENTS:

Y M D

Name of Medical Doctor (Print)

 

Speciality

 

Area Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

Signature of Medical Doctor

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

M

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service Canada delivers Employment and Social Development Canada programs and services for the Government of Canada

Print to PDF

SC INS5140 (2017-01-005) E

GIVE THE COMPLETED FORM TO THE PATIENT

DISPONIBLE EN FRANÇAIS - INS 5140 F

 

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