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In Your statement below when you have been sick for four days or more in a row. Your statement About you What date did you last work before your sickness began? DD MM YYYY Surname or family name First name(s) What time did you finish work on that date? (enter time in 24 hours) Title enter MR, MRS, MISS, MS, or other title Was your sickness caused by an accident at work or an industrial disease? National Insurance number No Yes If you answered Yes , you may be able to get Ind.

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