Employee’s Statement of Sickness

Your employer has sent you a link to this webpage because you have recently been off work due to illness.

Please complete the statement below, this will be used to determine whether you are entitled to Statutory Sick Pay

Statutory Sick Pay (SSP) is money paid by employers to emploees who are away from work because they are sick. Please fill in 'Your statement' below when you have been sick for four days or more in a row
Employer's Name(required)

Your statement

Surname or family name(required)
First or given name(s)(required)
Title - enter MR, MRS, MISS, MS or other title(required)
National Insurance Number
Date of Birth (DD/MM/YYYY - UK Format)(required)
Your email address(valid email required)
Tick this box if you want a copy of this statement sent to the email address above?
About your sickness. Please give brief details(required)
What date did your sickness begin?(required)
What date did your sickness end? If you do not know, please leave this blank
The dates you put in the above two boxes may be days you do not normally work. If you are sick for more than seven days, your employer may ask you for a medical certificate from your doctor. Medical certificates are also called sick notes or doctor's statements.
What date did you last work before your sickness began?(required)
What time did you finish work on that date?(required)
Was your sickness caused by an accident at work or an industrial disease?
No Yes
If you answered 'Yes', you may be able to get Industrial Injuries Disablement Benefit. If you want information about claiming this benefit, ask at any Jobcentre Plus office.

Signature and Date

This form will form part of a legal document; as such we require your signature. To do this we will need to create a digital signature, which will be made up of information known mainly to you.
Digitally signing this document will be the same as physically signing that this information is correct
The first three letters of your mother's maiden name(required)
The first three letters of the town of your birth(required)
The first three letters of the colour of your eyes(required)

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