Statutory Sick Pay (SSP)

Your Sickness - Overview
Please complete the following section about your sickness.
Please provide us with an overview of your sickness, with as much information as possible.*

Sickness and Leave Information
Please complete the following about your sickness and leave.
What date did your sickness begin?*
DD slash MM slash YYYY
Has your sickness ended?*
- Yes
- No
What date did you last work before your sickness?
DD slash MM slash YYYY
What time did you finish work on that day?*

: Hours

Minutes
Was your sickness caused by an accident at work?*
- Yes
- No

Your Assignment
Please complete the following information about your assignment.
Occupation*
Who is your client?*
Do you work with a Recruitment Agency?*
- Yes
- No
What is the name of your recruitment agency?*
What is the first name of your recruitment consultant?*
What is the last name of your recruitment consultant?*
Recruitment Consultant's Telephone Number*
Recruitment Consultant's Email Address*
What date did your assignment start?*
DD slash MM slash YYYY
Is your assignment fixed-term or open-ended?*
When is your assignment due to end?*
DD slash MM slash YYYY

Fit Note Information
Please complete the following questions.
Have you been issued a Fit Note? Please note we will require a copy of your Fit Note in order to process your application for Statutory Sick Pay - which you can upload later in this form.*
- Yes
- No
What date were you issued a Fit Note?*
DD slash MM slash YYYY
Start date for your Fit Note?*
DD slash MM slash YYYY
End date for your Fit Note?*
DD slash MM slash YYYY

Uploading your Fit Note
You can upload your Fit Note using the tool below.
Please upload your Fit Note using the button below (jpg, jpeg, png, doc, docx, pdf).*
Drop files here or

Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 256 MB, Max. files: 4.

Declaration
Please answer the following questions.
The information I have provided in this form is accurate and truthful.*
- Yes
- No
I understand that if the information I have provided is inaccurate or untruthful, my application for Statutory Sick Pay will become void.*
- Yes - I understand
- No - I do not understand

Additional Comments
If you would like to provide us with additional information, please enter it below.
More Information
Name
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Personal Information