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.
| Question | Answer |
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| Form Name | Sc Ins5140 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | medical certificate for employment pdf, ei medical certificate, medical certificate for sick leave, medical ei form |
Service |
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Canada |
MEDICAL CERTIFICATE |
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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 |
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Date of Birth |
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Last Name |
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First Name |
Initials |
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Full Postal Address |
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Number and Street, Concession, Other |
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Apt. No. |
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Area Code Telephone Number |
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City or Town |
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Province / Territory |
Postal Code |
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Signature of claimant, representative or next of kin |
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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.
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?
Y M D
What was the actual date of confinement?
Y M D
INCAPACITY
In my opinion, the above patient is incapable of working until:
Expected Recovery Date
Y M D
COMMENTS:
Name of Medical Doctor (Print) |
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Speciality |
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Area Code |
Telephone Number |
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Address |
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Signature of Medical Doctor |
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Date |
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Service Canada delivers Employment and Social Development Canada programs and services for the Government of Canada
GIVE THE COMPLETED FORM TO THE PATIENT
SC INS5140 |
DISPONIBLE EN FRANÇAIS - INS 5140 F |
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