Example of Work Incapacity Due to Illness Issued by Eps

Incapacity certificate

Company: (Name of the company or institution)

Document issue date ____ / ____ / ____

Certificate Number 2658

Type of care:

Work accident or illness

Information of the interested party:

Last name: _____________________
Mother's last name: _____________________
Names: ____________________________

Identity card No: 56287451

Medical history:

________________________________________________________

________________________________________________________

Disability start date: ___ / ___ / _____
Disability termination date: ___ / ___ / _____

Type of disability written in letters:

____________________________________________

Name of the doctor:
____________________________________________

Doctor's cello

Signature of authorized official Signature of worker