<p> LOC4 Q47 - Lancashire Area Team Application for Additional Payments during Confinement</p><p>Fill this form in and send it to Payments, PCSS (Preston Office), 3 Caxton Road, Fulwood, Preston, PR2 9ZZ together with a medical certificate for your confinement as soon as you have decided the date when you will give up work and you have made arrangements to engage a locum or deputy from outside the practice.</p><p>Before completing this form please refer to the guidance issued by the Joint Committee on Postgraduate Training for General Practice, which outlines the requirements when appointing a locum to cover your period of absence.</p><p>DETAILS OF GP APPLYING FOR ADDITIONAL PAYMENTS Surname: Initials: Local code number:</p><p>First day away from practice: Are you already receiving sickness payments under SFE 9? YES/NO</p><p>DETAILS OF LOCUMS OR DEPUTIES Surname: 1) 2) Forename: Address:</p><p>GMC Registration No. Are they on the NHS England performers □ Yes □ No □ Yes □ No list? </p><p>Name of Area Team: Personal number:</p><p>On what basis will they be employed: □ Full Time □ Full Time (locums count as full time if they work the normal hours, as approved by the Area Team of the practitioner they are deputising for)</p><p>□ Part Time □ Part Time Please give details Please give details</p><p>When will they start From: From: deputising for you as a locum or deputy? To: To:</p><p>Page 1 of 2 1 LOC4 OTHER RELEVANT INFORMATION</p><p>Is there any other relevant information that might affect this Yes No application? □ □</p><p>Please give details</p><p>DECLARATION OF THE GP APPLYING FOR PAYMENTS</p><p>I declare</p><p> That I intend to resume practice as a principle under the nGMS contract, provided that I am fit, within a reasonable time of the birth of my child.  That the information on this form is correct.  I undertake to inform the Area Team of any change in my deputising arrangements without delay. I apply for additional payments under SFE 9. I enclose a medical certificate for my confinement.</p><p>Signature:</p><p>Date:</p><p>Practice Stamp:</p><p>Page 2 of 2 2</p>