Republic of the Philippines

TECHNICAL EDUCATION AND SKILLS DEVELOPMENT AUTHORITY

ISO 9001: 2015 Certified

MEMORANDUM
Number 513 , s. 2020

TO All TESDA Officials and Employees

FROM The Director General

This Authority

DATE 27 November 2020

SUBJECT : Government Service Insurance System (GSIS) and

Employees' Compensation Commission (ECC) Benefits for
Employees Who Tested Positive with COVID-19

Per TESDA Memorandum No. 459, series of 2020 dated 27 October 2020, the
Employees' Compensation Commission (ECC) of DOLE assures assistance for public
sector employees who tested positive in COVID-19 through their Employees'
Compensation Program. The program is being implemented through the Government
Service Insurance System (GSIS).

All officials and employees who contracted COVID-19 are encouraged to claim
benefits from ECC/GSIS by submitting the following documentary requirements (copy
of the forms attached):

1. Duly accomplished Form for Income Benefit Claim for Payment, Parts I and II;
2. Duly accomplished Form for Hospitalization Claim for Payment, Parts I, II, and
III;
3. Hospital / Clinical records of confinement / consultation due to claimed
ailment; and
4. Service Record with Certification indicating the specific dates and time of sick
leave with and without pay.

The completely filled-up documentary requirements shall then be filed to the

nearest GSIS branch. Please note that Employee Compensation Medical
Reimbursement claims can only be filed after the EC sickness claim has been
approved by the GSIS. For assistance or further inquiries, you may contact Ms.
Marissa D. Medina of the Human Resource Management Division — Administrative
Service (HRMD — AS) at TESDA local number 319 or (02) 8817 2516.

For your information and guidance.

Oe
SEC. ISIDRO S LAPERA, PhD, CSEE
Director General sp

East Service Road, South Luzon Expressway (SLEX), Fort Bonifacio, Taguig City 1630 ••••• •
Land Line: (+632) 8888-5641 to 46 CP Number: (+63) 917-4794370 (text only) Telefax No: (+632) 8893-2454
www.tesda.gov.ph , contactcenter@tesda.gov.ph TESDA Lahat
 PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN
(GOVERNMENT SERVICE INSURANCE SYSTEM)
Financial Center, Pasay City, Metro Manila 1308
GSIS
DOCUMENTARY REQUIREMENTS
EMPLOYEES COMPENSATION / al3)\&0 70121/11
1. Sickness
a) Duly accomplished Form for Income Benefit Claim for Payment, Part I and II
b) Duly accomplished Form for Hospitalization Claim for Payment, Parts I, II,
and III
c) Hospital/ Clinical records of confinement/ consultation due to claimed
ailment
d) Service Record with Certification indicating the specific dates and time of
sick leave with and without pay

2. Injury (Non-battle)
a) Duly accomplished Form for Income Benefit Claim for Payment, Part I and II
b) Duly accomplished Form for Hospitalization Claim for Payment, Parts I, II,
and III
c) Hospital/ Clinical records of confinement/ consultation due to claimed
ailment
d) Service Record with Certification indicating the specific dates and time of
sick leave with and without pay
e) Certification under oath by Head of Office narrating in detail the
circumstances surrounding the accident (e.g. time, date, place of accident,
what employee was doing at the time of accident and reason or purpose of
being there)
f) Affidavit of witnesses to the accident
g) Travel/ Mission Order/ Personnel Pass, if injury/ accident happened outside
office premises
h) Police Accident/ Investigation Report, if applicable (e.g. vehicular accident,
shooting incident, stabbing incident, etc.)
i) Line of Duty Board Proceedings for AFP members

3. Wounded in Action (WIA)

a) Duly accomplished Form for Income Benefit Claim for Payment, Part I and II
b) Duly accomplished Form for Hospitalization Claim for Payment, Parts I, II,
and III
c) Hospital/ Clinical records of confinement /consultation due to claimed
ailment
d) Service Record with Certification indicating the specific dates and time of
sick leave with and without pay
e) Certification under oath by Head of Office narrating in detail the
circumstances surrounding the accident (e.g. time, date, place of accident,
what employee was doing at the time of accident and reason or purpose of
being there)
f) Authenticated copy of Operations Center Journal Entry
g) Original or Authenticated copy of Spot Report
h) Original or Authenticated copy of Progress Report
 IS Government Service Insurance System
GS
DISABILITY BENEFITS
INCOME BENEFITS CLAIM FOR PAYMENT
PART I — EMPLOYEE TO FILL IN ALL ITEMS
EMPLOYEE NAME (LAST, FIRST, MIDDLE) CIVIL STATUS ❑ Married ❑ Separated
❑ Single ❑ Widow/Widower
GSIS POLICY OR BP NUMBER
HOME ADDRESS GENDER ❑ Female CI Male
DATE OF BIRTH
DATE OF ORIGINAL APPOINTMENT
PLACE OF BIRTH

ACTUAL DUTIES: MONTHLY SALARY:

BASIC:
ALLOWANCE:
CERTIFICATION:
DEPENDENTS DATE OF BIRTH RELATIONSHIP
I CERTIFY THAT I USED _ _ DAYS OF
, HOSPITALIZATION AND WAS PAID BY MY EMPLOYER AN
AMOUNT OF CHARGEABLE AGAINST
2. MY LEAVE CREDITS.
3. SIGNATURE OF EMPLOYEE/CLAIMANT
4. OF UNABLE TO WRITE AFFIX thUMbrnark) CLAIMANT'S RIGHT
5. THUMBMARK
6.
7. WITNESS TO THUMBMARK
8. 1.
WORKING HOURS:
SPECIFIC PLACE OF WORK: 2.
Have you received or recovered any amount of damages connected with this claim from third part/ies. If you, state amount, name and address of
such third party

If no, do you intend to recover any amount or damages from 3rd person?

If yes, please state name and address of such 3rd person

Have you chosen benefits under other laws? If yes, what benefit and under what law?

Have you received benefits thereunder? How much have you received?

PART H — EMPLOYER TO FILL IN ALL TIMES

EMPLOYER'S REGISTERED NAME DATE AND PLACE OF INJURY / SICKNESS / DEATH

ADDRESS OF EMPLOYEE TIME: Was the employee injured in regular occupation?

Nature or kind of injury / Sickness I Disability I Death (Describe fully CERTIFICATION:

how accident happened and what the employee was doing at the time of I hereby certify that the contingency has been properly recorded in
injury, sickness, disability or death) our log book under Entry No.
dated . I further certify that
Mr./Ms./Mrs has not
filed ally claim under any other benefits for the same injury, disability
or death. Should any claim be filed, that office will be informed
immediately.
SIGNATURE OF AUTHORIZED OFFICIAL CAPACITY
REPRESENTATIVE

Printed Name Of Employer's Authorized Representative:

Has injured stopped working? _ Amount of salaries paid Equivalent Number of Days
If so, has he returned to work? for the days of absence
When?

(If papers submitted are not sufficient additional documents may still be required)
NOTE: Anyone who falsifies essential information requested by this or a related form may, upon conviction be subject to fine and imprisonment
under the law. All data required on this form are necessary for adjudication of the claim. The GSIS will adjudicate any claim where
forms are not properly or completely accomplished.
 MEMBER'S SERVICE RECORDS

NAME
(Print or type) (Surname) (Given) (Middle Name)

ADDRESS GENDER ❑ Female ❑ Male

(Station or Place of Assignment)
CIVIL OSingle EI Married
DATE OF BIRTH PLACE OF BIRTH STATUS Separated ❑ Widow/Widower

SERVICE
RECORDS OF APPOINTMENT Leave of
(Inclusive Datt) Office of Entity
Absences REMARKS
Status or Division
From To Designation Basic Salary Allowance without pay
(Perm/Temp)

CERTIFIED CORRECT:

Signature of Authorized Representative

(Employer)

Date of Registration of Employee

Number of Monthly Premium Paid

Life Retirement Medicare Employee Compensation

CERTIFIED CORRECT:

Chief, Billing Division

 HOSPITALIZATION CLAIM FOR PAYMENT
EMPLOYEE'S COMPENSATION
PART I - HOSPITAL TO FILL IN ALL ITEMS
Hospital Address PMC No.

Patient/Employee Date Admitted Date Discharged Date of Death

Diagnosis Hospital Charges(Ward Serv'ces) BC Actual

A. Room Board & Special Charges
_____ days at Php_____________
Final Diagnosis
B. Surgical
GSIS No. Gender i Age C. Medicines
❑ Female
❑ Male
Address of Employee CERTIFICATION
I hereby certify that the services claimed are duly recorded in the patient's
Employer chart and the information given in this form, including the attached copy of the
patient statement of actual charges is correct.
Address of Employer
Printed Name of Hospital Authorized Representative
For GSIS Use (Signature Verified by)
Official Capacity
Remarks
Signature of Authorized Representative Date Signed

PART 11 - DOCTOR TO FILL IN ALL ITEMS Do not Fill

Brief Clinical History of the Case (For clarification, use reverse side hereof)

Code No.
For services rendered always state the nature of service, surgical CHARGES
operation performed, if any, and date of each EC Actual
A. Name of Attending Physician/Surgeon Address

Signature Date Signed

Php Php
PMA No. TIN
Services Rendered

B. Name of Attending Physician/Surgeon Address

Signature Date Signed

Php Php
PMA No, TIN
Services Rendered

C. Name of Attending Physician/Surgeon Address

Signature Date Signed

Php Php
PMA No, TIN
Services Rendered

MEDICAL EVALUATION REPORT (For GSIS use only)

Nature or Degree of Sickness/Sickness
Noted
Signature
Designation
Date

NOTE: Anyone who falsifies essential information requested by this or a related form may, upon conviction be subject to fine and imprisonment
under the law, All data required on this form are necessary for adjudication of the claim. The GSIS will adjudicate any claim where
forms are not properly or completely accomplished.
 PART HI - ATTENDING PHYSICIAN'S CERTIFICATION (Fill in All Items)
Name of Employee Treatment Period (exact date)

From: To:

History of present illness: (Give exact date, if possible and include signs Pertinent P.E. Findings and Laboratory procedures:
and symptoms up to the time of this report)

Past history (only those relevant to present illness)

Final Diagnosis:

Was the injury or illness directly caused by the employee's duties?

Degree of disability Was patient working at the time of the illness?

❑ Temporary total

❑ Permanent total

❑ Permanent partial

Medical Evaluation Report (for GSIS use only)

M.D.
Signature over printed name

PMA No. BIR TIN

Llc. No Date Issued

/akla retyped as of 23 July 2014