report claim - pfa occupational capacity

Phone
*
E-mail
*
Civil reg. No.
*
Yes
No
*
If yes, as of when
If no, how many hours do you work per week
*
Yes
No
Don't know
*
If yes, when
Employee
Self-employed
*
Name of employer
Yes
No
Yes
No
If yes, date of resignation
If yes, date of cessation of salary
Yes
No
*