Republic of the Philippines Ww SOCIAL SECURITY SYSTEM 7 | SICKNESS BENEFIT APPLICATION SIC- 01250122015) _ (FOR SELF-EMPLOYED/VOLUNTARY MEMBER & MEMBER SEPARATED FROM EMPLOYMENT) PART I- TO BE FILLED OUT BY MEMBER 7 PERSONAL DATA Sor [STON REFERENCE MER oR Fm, — ATE OF BATH sony GENT CATON OMEN ls ik aiff |i pf ORR ys i | be Lae Lk Sr Lah Som AORESS REARS TERET TET EET sa SRRETSETSSTT SRT RE FORE [TELEPHONE NUMBER yecacoce-ra no) |MOBILE/CELLPHONE NUMBER JE-MAIL ADDRESS Ll He SE pea ESS | | if Oss Oec O Home C1 xosprrat |DATE OF SEPARATION FROM LAST EMPLOYER: TB MEMBER'S ENROLLMENT INTHE PAYMENT THRU THE BANK (V not yet enroed] [BANK RANE AND BRANCH IBANK BRANCH ADDRESS fzP CODE |BANKAGCOUNT NAVE TE Sn ee [C savncsicurnenT —C] UMIDATM ACCOUNT LI CASH CARD: VALID UNTIL TLCERTHICATION el | certify that the information provided in this form are rue and correct. PRINTED NANE ‘SIGNATURE DATE I member cannot sign, affix fingerprints. Please read Instruction No, 6 ofthe form, Bolow are the witnesses to fingerprinting esis PRINTED NAME ‘SIGNATURE DATE [ADDRESS & CONTACT NUMBER eee PRINTED NAME ‘SGRATORE TATE RIGHT THUMB RIGHT MEX [ADDRESS & CONTACT NUMBER PART IVA, MEDICAL CERTIFICATE (TO BE FILLED OUT BY THE ATTENDING PHYSICIAN) TBREF MEDICAL HISTORY AND PERTINENT FINDINGS "ATTENDING PHYSICIAN'S CERTIFICATION | cert ha have geen and examined above-named patient on and in my opinion, confinement aay Including recuperation pred may ast. ays. (no of ave) DIAGNOSIS PLAGE OF CONFINEMENT [START OF CONFINEMENT NAME OF HOSPITAL (Feonfned ma hosp O vows Chvosera, fer fee PRINTED NAME AND SIGNATURE TICENSENO) [ADDRESS OF PHYSIGANS CLNIGIHOSPITAL —WOsSTRIED ro Toma TarRomnee — JEP CODE FILLED OUT BY S55 PERSONNEL IRECEIVED BY (FOR NEDICAL EVALUATION SECTION) [RECEIVED BY (FOR NENBER SERVIGES SECTION) ‘SIGNATURE OVER PRINTED NAME _— DATE, TE, ‘SIGNATURE OVER PRINTED NAME, DATE THe Pererate Here = ————— ‘SOCIAL SECURITY SYSTEM SICKNESS BENEFIT APPLICATION ACKNOWLEDGEMENT STUB. AE OF WEER (AST HAE) HRT TOO WATE a iets | IRECEIVED BY “SIGHATURE OVER PRINTED RANE OF RECEIVING PERSONNEL DATE ETE, SES ERAN wi 88 gor ph OF career Coll Contr et O20S44S Up OSS oF OTT-TITTINSTRUCTIONS 41, Fillout this form in one (1) copy. 2, Always indicate "N/A" or “Not Applicable", if the required data Is not applicable. 3. Write S$ number and name of member in all ‘supporting documents for submission. 4. Present valid identification cards/documents. Refer to attached "List of Filer's Valid Identification (1D) Cards/Documents’ 5. if member cannot sign, witnesses to fingerprinting shall be as follows: Filed by member + SSS receiving personnel who shall affix his/her signature on the portion provided in Part -C and indicate employee ID No. Filed by me rn + Two (2) witnesses, One (1) is the member's authorized representative and the other one (1) could be any person. Both should affix their signatures and indicate their addresses ‘and contact numbers on the portions provided in Part I-C. 6. Accomplish Part |-B of this form, if not yet enrolled in the Payment thru the Bank Program. 7. Secure Letter of introduction (LO!) form from SSS, without existing single savings or current account, which shall be presented to the SSS-accredited bank chosen for purposes of opening single savings accounticash card account. 8 Submit this form to the nearest SSS branch office together with the following documentary requirements: ‘Bank documents (photocopy/scanned copy of any of the following, to ascertain correctness of bank ‘account information. ATM Card (with account number) Bank Account Passbook Bank StatementCertificate Deposit Sip/Savings account number card Sickness benefit payments shall be remitted by the SSS to member's designated bank 4. Additional Required Documents Present the original/certiied true copy and submit the photocopy of the following, whichever is applicable: 4.1 For Self-Employed/Voluntary Member (previously employed) hin the period of * Certificate of separation from employment with effective dale of separation and no advance payment was granted (signed by the employer's authorized signatory reflected in the Specimen Signature Card [SS Form L-501)) nfinement period applied fori 4.2 For Member Separated from Employment If-confinement period applied for is witis ‘employment or prior to date of separation * Certificate of separation from employment with effective date of separation and no advance payment was granted (signed by the employer's authorized signatory reflected in SS Form L601) It-confinement period applied for is after the date of ti * Certificate of separation from employment with effective date of separation (signed by the employer's authorized signatory reflected in SS Form L-501) Certificate of separation is _not_required for self- ‘employedivoluntary member (previously employed) or member separated from employment under any of the following ‘conditions in which supporting documents shall be required to be submitted as enumerated below: {Lcompany ison strike ‘+ Nolice of sirke duly acknowledged by the DOLE: and ‘© Duly notarized Affidavit of Undertaking issued by the member that no advanced payment was granted ‘company has been dissolved or has ceased operation * Duly notarized Affidavit of Undertaking issued by the member that no advance payment was granted and with indicated effective date of separation ». SSS Medical Certificate Form filed out by attending physician if there i a Supporting Medical Document, i any. ‘of member s ‘= Certication from DOLE; and Laboratory, X-ray, ECG and other diagnostic * Duly notarized Affidavit of Undertaking issued by the results; member that no advance payment was granted and with Y Operating roomiclinical record that will a ccace cea) eetreecl support diagnosis or vehi nt with Involvement _If_separated from employment due to AWOL or with strait (ECclaim) relations with the employer ir ene, + Duly notarized Affidavit of Undertaking issued by the oo ‘member that no advance payment was granted and with indicated reason and effective date of separation WARNING ‘ANY PERSON WHO MAKES ANY FALSE STATEMENT IN THIS APPLICATION OR SUBMITS ANY FALSIFIED DOCUMENTS IN CONNECTION WITH THE APPLICATION WITH THE SSS SHALL BE LIABLE CRIMINALLY UNDER SECTION 28 OF RA 8282 OR UNDER PERTINENT PROVISION OF REVISED PENAL CODE.ora TE ER Fay SSMUMBER RANE OF WENEER 7 PART I T0 BE FILLED OUT BY 555 PERSONNEL 7 SCREERNG RESULTS [nENGER SERVICES SECTION MEDICAL EVALUATION SECTION [srenna was done and resus ar stows [serena as done and resuts areas cows 1D inowee TD inoner 1G No sqneure ot ember Bat teaogs, paso 500 romans 1B Meseal Cente a sccomptsned ReMaRKs, Remarks [SCREENED BY SCREENED SRRTURE OVER PRINTED NE Da Te SIGRATORE OVER PRINTED NE, DAE THe TE PAVENT THRU THe BANK PROGRAM TREASON FOR EXEWPTION FROM THE PROGRAM RES IES Worbors ancurt of benefits one tousand pesos (P7000) and Boiow Member's adress is beyond 30 kms tothe nearest SSS-accredied bank Members adress isin igh rik 1S Memes physical incapable of transacting business wi he bank Somers JSCREENED AND ENCODED BY jpevieneo ey ‘SGRATORE OVER PRINTED NAVE DATE THE BRANCH READ Date SIGNATURE OVER PRINTED NAME TOREDICAL EVALUATION Tri Physcal amination and ntariow [PERTRENT Pe FRONGS ptember io atc agnatue ater PED ‘Onset finese Last wong Oy Backto Work Harbars Snaiare ES = PROVED Hof days larPRovEo #ot cave Dinu ZS eension inate prevousaprova CO trwat Z] Beenson irateat previous aopova Twnmeich Treo Terenas) Tewoeey Thabane Perea) Trauave Peasy DDrevius aprova irre approve Cosa (Cortes) Drospat carne) Tose ras) pastor) (Crenone Ofer mes ‘Qen}005 tera Coren: rors (Oicn/005 rte coy Dae roy aie Drervaeo (Dperumnen rea Date Tata Dae Coenteo Deen frewanns Ras jciness cooEs levaLuaTeD BY [ENCODED INO RELEASED BY SIGHATURE OVER PRINTED RANE Dae TSIGRRTURE OVER PRINTED NAME Dare PARTI PROCESSING CENTER [FORNTTACFUNe PROCESSING RESTS |processec' AND ENCODED EY ‘SIGRATURE OVER PRINTED WANE oaTE TSGRATORE OVER PRINTED RANE DATE JReveW RESULTS [CONCURRED By © Asproved 1D Reeces bees REVIEWED By SIGRATURE OVER PRNTED ANE ORE ‘STORE OVER PRINTED WE DAE FoRREFIED CLAM PROCESSING RESULTS | ener aE STREP oe VIEW RESULTS [CONCURRED BY 1D Arproved 1D enced 1 bene REVIEWED BY SGRATRE VER PRNTED INE DAE SIGRATORE OVER PRINTED WANE DRELIST OF FILER’S VALID IDENTIFICATION (ID) CARDS/DOCUMENTS Sickness Benefits Process Primary ID Cards/Documents Social Security (SS) card Unified Multi-Purpose ID (UMID) card Passport Professional Regulation Commission (PRC) card 5. Seaman's Book (Seafarer's Identification & Record Book) Bena . Secondary ID Cards/Documents ‘Alien Certificate of Registration ‘ATM card (with cardholder's name) Bank Account Passbook Company ID card Certificate of Confirmation issued by National Commission on Indigenous People (formerly Office of Southern Cultural Community and. Office of Northern Cultural Community) 6. Certificate of Licensure/Qualification Documents from Maritime Industry Authority 7. Certificate of Naturalization 8 Credit card 9. Court Order granting petition for change of name or date of birth 10. Driver's License 11. Firearm License card issued by Philippine National Police (PNP) 12. Fishworker's License issued by Bureau of Fisheries and Aquatic Resources (BFAR) 13, Government Service Insurance System (GSIS) card/Member’s Record/Certificate of Membership 14, Health or Medical card 1. Home Development Mutual Fund (Pag-IBIG) Transaction Card/Member's Data Form 16. ID card issued by Local Government Units (LGUs) (e.g. Barangay/Municipality/City) 17. ID card issued by professional association recognized by PRC 18. Life Insurance Policy of member 19. Marriage Contract/Marriage Certificate 20. National Bureau of Investigation (NBI) Clearance 21. Overseas Worker Welfare Administration (OWWA) card 22. Philippine Health Insurance Corporation (PHIC) ID card/Member's Data Record 23, Police Clearance 24, Postal ID card 25. School ID card 26. Seafarer's Registration Certificate issued by Philippine Overseas Employment Administration (POEA) 27. Senior Citizen card 28. Student Permit issued by Land Transportation Office (LTO) 29, Taxpayer's Identification Number (TIN) card 30. Transcript of Records 31. Voter's Identification card/Voter’s Affidavit / Certificate of Registration eens 1 Filed by Member Present original of any one (1) of the primary ID cards/documents in Item A or two (2) ‘Secondary ID cards/documents in Item B both with signature and at least one (1) with photo. Filed by Member's Representative Present the following 2.1. Original of any one (1) of the Authorized Representative's primary ID _cards/ | documents in Item A or two (2) secondary ID cards/documents in Item B both with signature and at least one (1) with photo; and 2.2 Original of any one (1) of the Member's primary ID cards/documents in Item _A or | two (2) secondary ID cards/documents in Item _B ‘both with signature and at least ‘one (1) with photo,