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).
Group
Employment Insurance
Forms
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Important Information
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Employment and Social Development Canada
Compassionate Care Benefits - Annex 5
PDF: Download ESDC-INS5217, 191 KB, printed on 2 pages (8.5x11)