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Number INS5217
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).
GroupEmployment Insurance
Important Information
Returning the Form

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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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