Serious Illness Benefit

Application for Serious Illness Benefit
Name

First NameLast Name
Business address and postcode
Home address and postcode
Email address
example@example.com
Date of birth

MonthDayYear
Date
Contact number
Best time to contact
Medical statement (Give full details of the serious illness from which you are suffering, and why this has resulted in your being unable to work long-term with your business)
Enter bank details to where you wish the award made to you credited
Bank name
Account holder name
Sort code
Account holder
Confidentiality statement

I understand that by completing this application and sending supplementary evidence that I will be providing the Fed with personal information which will be held securely by the Benefits Manager.
Any additional comments you wish to add to your application
Upload any supporting documents that you may have

Cancelof
Statutory statement: I declare that the information I have provided in this application is true and correct.
Should be Empty:

Enter bank details to where you wish the award made to you credited