Annex 5 – Compassionate Care Benefits in Canada Form INS5217 may be downloaded here to apply 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).
The information provided on this form is administered in accordance with the Employment Insurance Act and the Privacy Act. Individuals have
the right to protection of, and access to, their personal information. The information will be retained in the Personal Information Bank No.
ESDC PPU 150. Instructions for obtaining this information are outlined in the government publication entitled Info Source, a copy of which is
located at all Service Canada Centre. Info Source is also available at the following web site address: infosource.gc.ca
The information you provide is collected under the authority of the Employment Insurance Act to determine your eligibility for benefits.
Completion is mandatory; failure to complete this form will result in not being entitled to Compassionate Care Benefits. The
information you provide may also be used for policy analysis, research and/or evaluation purposes. In order to conduct these activities, various
sources of information under the custody and control of ESDC may be linked.
The information you provide may be shared with other family members who claim EI Compassionate Care Benefits.
For Further Details of Compassionate Care Benefits in Canada: Click Here