|Title||Annex 5 - Compassionate Care Benefits|
|Purpose||Complete this form if you are applying for Compasionate Care Benefits. This form must be submitted with the Authorization to Release a Medical Certificate (INS5216A) and the Medical Certificate for Employment Insurance Compasionate Care Benefits (INS5216B).|
Returning the Form
|Employment and Social Development Canada|
Compassionate Care Benefits - Annex 5
PDF: ESDC-INS5217, 197 KB, printed on 2 pages (8.5 x 11)
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