The Self Employed Statutory Sick Pay Form Template UK is provided in multiple formats, including PDF, Word, and Google Docs, featuring customizable and printable versions.
Self Employed Statutory Sick Pay Form Template UK Editable – PrintableSample
Self Employed Statutory Sick Pay Form Template UK 1. Personal Information 2. Nature of Self Employment 3. Sick Leave Details 4. Medical Information 5. Evidence of Sickness 6. Confirmation of Earnings 7. Declaration of Self Employment 8. Agreement and Consent 9. Additional Information 10. Declaration and Signatures
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[Name of the Self-Employed Individual]
[National Insurance Number]
[Address]
[Phone Number]
[Email Address]
[Name of the Business (if applicable)]
[Business Registration Number]
[Business Address]
This form is to claim Statutory Sick Pay (SSP) due to illness for a period of at least [minimum period, e.g., 4 consecutive days].
Start Date of Self-Employment: [Start Date]
Nature of Self-Employment: [Description of Work/Profession].
Start Date of Sick Leave: [Start Date of Sickness]
Expected Return Date: [Expected Return Date].
Please provide a statement from a qualified medical practitioner confirming your absence due to illness.
Date of Medical Consultation: [Date].
Average Weekly Earnings: [Average Earnings over last 8 weeks].
Provide details of any other sources of income during the sick leave period.
Account Holder Name: [Your Name]
Bank Name: [Your Bank’s Name]
Account Number: [Your Account Number]
Sort Code: [Your Sort Code].
[Signature of the Applicant]
[Name of the Self-Employed Individual]
[Name of the Self-Employed Individual]
[National Insurance Number]
[Address]
[Phone Number]
[Email Address]
[Business Name]
[Type of Business]
[Business Address]
This form is to formally apply for Statutory Sick Pay due to inability to work from [Start Date] until [End Date].
Start Date of Self-Employment: [Start Date]
Nature of Self-Employment: [Business Description].
Total Days Absent: [Number of Days]
Last Working Day: [Last Working Day].
Attach a medical certificate verifying your illness and inability to perform work duties.
Date of Issue: [Date].
Average Earnings Before Sickness: [Earnings Details].
Other Income During Illness: [Describe any other income].
Account Holder Name: [Your Name]
Bank Name: [Your Bank’s Name]
Account Number: [Your Account Number]
Sort Code: [Your Sort Code].
[Signature of the Applicant]
[Name of the Self-Employed Individual]
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