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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 that the patient is unable to work for medical reasons.

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

' Section 4 - Patient information

Last name

HOLAND

First name
MARK

Social insurance number (999 999 999) | Date of birth (YYYY-MM-DD)
730 742 368 1978-09-04

|Apartment number | Street number and name

City or town Telephone number (999) 999-9889

(236) 994-3376

NEW WESTMINSTER

Postal or ZIP code
| : V3L 093
a

Section 2 - Certificate of medical practitioner
2926-01-30

' In my opinion, the above patient is unabie to work for medical reasons from
now ~ ott- 30

| (YYYY-MM-DD).
‘Name of medical practitioner (Print)

On CRsteome Roe)
| Address

429 CanmhiA SmFE Y3u iG] —

(YYYY-MM-DD) up to and including

Speciality

Privacy Notice Statement

The personal information provided on this form:

* 15 collected under the authority of the Employment Insurance Act and the Department of Employment and Social Development Act for the purpose of the
administration of the El Program;
will be managed and administered in accordance with the Department of Employment and Social Development Act, the Privacy Act and other applicable laws;

may be shared by ESDC 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 they are responsible,

may be used or 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 any other individual whose information is included in this form,

is described in the Personal Information Bank: Employment Insurance Claim Files (PIB) (ESDC PPU 151).

individuals have the right to the protection of, access to and correction of their personal information. Instructions for obtaining the personal information provided
on this form are outlined in the government online publication Info Source available at www.canada.cav/infosource-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/an/report-a-concem.

SC INS5140 (2025-01-007) E

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