ACCIDENT/SICKNESS REPORT for EC Claim

Emp ID: Full Name: Client Name:

Date of Accident/Sickness: Exact Time of Accident/Sickness: Place or Location of Accident/Sickness:

Period of Incident: (based form Exact time of accident or sickness)

During REGULAR working Hours? Overtime? ______________________

DATE LAST REPORTED FOR WORK: DATE RETURNED TO WORK:

INCLUSIVE DATES OF LEAVE OF ABSENCE:

Brief Summary of Job Description or Occupation (Please indicate as well type of work-setting)

BRIEF DESCRIPTION OF ACCIDENT/SICKNESS

Prepared By Employee Relation: Noted By:

____________________________________________ ATTY. FIDEL L. ESTEBAN

Signature above printed Name & Date Manager Employee Relations

+++++++++++++Portion Below to be filled out by our Team+++++++++++++++++++

I certify that the above information is true and correct and that the reported
accident/illness is duly recorded in the Employer’s Logbook for EC Claim under page number
_________ and entry number ________.
_______________________________ _________________ ___________
SIGNATURE OVER PRINTED NAME AUTHORIZED SIGNATORIES OFFICIAL DESIGNATION DATE

Please see snipped below copy of EC-Logbook

Collabera Technologies Private Limited, Inc. 40th Floor, Rufino Pacific Tower, 6784 Ayala Avenue cor. V.A.
Rufino St., Makati City 1226 Philippines.
Tel: +632 76250367 | phlegalcompliance@collabera.com
Collabera Technologies Private Limited, Inc. 40th Floor, Rufino Pacific Tower, 6784 Ayala Avenue cor. V.A.
Rufino St., Makati City 1226 Philippines.
Tel: +632 76250367 | phlegalcompliance@collabera.com