Common use of Employee Statement Clause in Contracts

Employee Statement. TO BE COMPLETED BY EMPLOYEE PRIOR TO SUBMITTING TO PHYSICIAN (Please PRINT) Name: Department: Employee No: Phone: Email: Start of Present Absence: (day/month/year) Occupation/Title: Employee Authorization: The above information is accurate to the best of my knowledge, and I hereby authorize my physician to exchange the following and subsequent information to and or from Return to Work Services, Human Resources in respect to my claim for short term disability benefits and to assist in my participation in a RTW Program. A copy of this consent shall be considered valid authorization throughout the duration of my claim and during participation in a return to work program. I further agree to the recovery of sick benefits received in the amount of 20% per pay cheque if it is found that the functional information provided does not support an absence from work. Employee Signature Date: (day/month/year)

Employee Statement. TO BE COMPLETED BY EMPLOYEE PRIOR TO SUBMITTING TO PHYSICIAN (Please PRINT) Name: Department: Employee No: Phone: Email: Start of Present Absence: (day/month/year) Occupation/Title: Employee Authorization: The above information is accurate to the best of my knowledge, and I hereby authorize my physician to exchange the following and subsequent information to and or from Return to Work Services, Human Resources in respect to my claim for short term disability benefits and to assist in my participation in a RTW Program. A copy of this consent shall be considered valid authorization throughout the duration of my claim and during participation in a return to work program. I further agree to the recovery of sick benefits received in the amount of 20% per pay cheque if it is found that the functional information provided does not support an absence from work. Employee Signature Date: (day/month/year)

Employee Statement. TO BE COMPLETED BY EMPLOYEE PRIOR TO SUBMITTING TO PHYSICIAN (Please PRINT) Name: Department: Employee No: Phone: Email: Start of Present Absence: (day/month/year) Occupation/Title: Employee Authorization: The above information is accurate to the best of my knowledge, and I hereby authorize my physician to exchange the following and subsequent information to and or from Return to Work Services, Human Resources in respect to my claim for short term disability benefits and to assist in my participation in a RTW Program. A copy of this consent shall be considered valid authorization throughout the duration of my claim and during participation in a return to work program. I further agree to the recovery of sick benefits received in the amount of 20% per pay cheque if it is found that the functional information provided does not support an absence from work. Employee Signature Date: (day/month/year)