Bw Service PROTECTED WHEN COMPLETED - B
Canada :

Medical Certificate for Employment Insurance Sickness Benefits
An individual must get a medical certificate signed by a medical practitioner when they apply for Employment Insurance (El) sickness benefits,
The medical practitioner completes and signs Section 2 to attest thal the patient is unable to work for medical seasons.

For more information about El sickniess benefits, including medical practitioners who can complete and sign this form, visit Employment Insurance benefits
(canada.ce/ei),

Section 1 - Patient information eae BES eee
Last name First name Social insurance number (299 999 999) | Date of birth (YYYY-MM-DD)
ROLAND. MARK 730 742 368 1978-03-04

Apartment number | Street number and name Cily or lown Telephone number (999) 999-9999
318 AGNES ST NEW WESTMINSTER (236) 994-3376

Province, tertitory or state Postal as ZIP ‘cade Country
V3L 993 CANADA

In my opinion, the above patient is unable to work for medical reasons from202 6-02-02 (YYYY-MM-DD) up to and including
2O%be ~oF - 3!
(YYYY-MM-DD),
Name of medical practitionor (Print) Specialily

ee GecctrAcé. Prob onr unr) fA» >) meaiciwe
Aildtees Date (YYYY-MM-00)
422 Commu Bi SN eec : orb 0 &-|z

Privagy Notice Statement

The personal information provided on this form:
* |s collected under the authority of the Employment Insurance Act and the Department of. Employment and Social Development Act for the purpase of the
administration of the El Program; ¥
* wil be managed and administered in accordance with the Deparment of Emplayment and Social Devefopment Act, the Privacy Act and other applicable laws;

* may be shared by ESOC with federal departments and agencies involved in the administration of benefits and services, or with federal and provincial
departments for the administration and enforcement of the legislation for which thay are responsible;

* may be used ar disclosed for policy analysis, research or evaluation purposes. These uses or disclosures will not result in any decision that may directly affect
the claimant or aby other individual whose information is Included in this form;

* is described in the Personal Information Bank: Employment Insurance Claim Files (PIB) (ESDC PPU 181),
Individuals have the right to the protection of, access to and correction of thelr personal information. Instructions for cbtaining the personal information provided

on this form are outlined in the government online publication Info Source available at www.canada.cafinfosource-ESDC: Info Source can also be accessed at
any Service Canada Centre. Individuals who-are not satisfied with ESDC's response to their privacy concerns can contact the

Office of the Privacy Commissioner of Canada at www.priv.ge.ca/en/report-a-concem.

SC INS5140 (2025-01-007) E Page-1 of 1 Canadit