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* 1. State your name

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* 2. State your National Insurance registration number

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* 3. Please indicate your gender

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* 4. In which industry do you work?

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* 5. Are you self-employed?

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* 6. What is the name of the business/organization you are employed with?

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* 7. Please indicate the period for which you would be unemployed.

Date
Date

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* 8. Please indicate what percentage of your monthly income you have lost.

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