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Application To Be Ill

This form must be submitted at least 21 days before the date on which you wish the illness to commence :-

Name……………………………………………………

Position Held……………………………………………


Nature of illness………………………………………...

Date of which you wish illness to commence…………………………………
(Applications to suffer from Pregnancy must be submitted 12 months prior and accompanied by Form No. WS.361214198) Consent of Husband/Wife

Have you ever applied to suffer from this illness before………………………
If so, give date………………………………………….

Do you wish the illness to be slight/crippling/fatal……………………………
If illness is fatal do you wish this to be considered a permanent disability…………………………………
(Applicants wishing to suffer a fatal illness should indicate at the foot of this form whether they wish:-Board of directors to be represented at the funeral/cremation)

Do you wish to suffer from this illness at home/hospital/Costa Brava/ Newport Pagnell/Milton Keynes……………………………………

Do you wish this illness to be of a contagious nature………………………….
If so, indicate approximate number of people you wish to infect………………

Have you ever been refused permission to suffer from an illness………………
If so, give details…………………………………………………………………

Do you wish your wife/husband to be informed of your illness if he/she contacts us…………………………………………

I, the undersigned declare that to the best of my knowledge the answers given above are true and accurate.

Signed……………………….. Date…………………………..

Applicants are reminded that all applications will be considered on merit and that more than three applications per annum will be considered excessive and not in the best interests of the company. Under NO CIRCUMSTANCES will any employees be granted more than one FATAL ILLNESS per year.