Transcription of SICKNESS BENEFIT APPLICATION FORM
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Example: tourism industry
SICKNESS BENEFIT APPLICATION FORM
CLAIM FILEDCLAIMANT(FIRST, MIDDLE INITIAL, LAST)SS NUMBERDATE OF BIRTHDATE WHEN EMPLOYEEBECAME SS MEMBERADDRESS (GIVE FULL ADDRESS)DATE WHEN CLAIMANTNOTIFIED SSSCONFINEMENTA. STARTED ON (FROM)B. ENDED UP TO (LAST DAY)C. PLACE CONFINEDD. NO. OF DAYSHOSPITALHOMEWERE YOU EMPLOYED AT ANY TIME DURING THE PERIOD OF SICKNESS FOR WHICH BENEFIT IS BEING CLAIMED? (PLEASE CHECK PROPER BOX.)(FILL UP SUCCEEDING DATA)EMPLOYERYESNOLAST EMPLOYER(FILL UP SUCCEEDING DATA)ADDRESSADDRESSPERIOD OF employment (EXACT DATES)EMPLOYER NO. EXACT DATE OF SEPARATIONTOTAL MONTHLY SALARY CREDITSCERTIFICATION OF SEPARATIONTHIS IS TO CERTIFY THAT THE CLAIMANT HAS BEEN SEPARATED FROM COMPANY EFFECTIVE _____ NAME AND SIGNATURE OF COMPANY REPRESENTATIVEOFFICIAL DESIGNATIONI HEREBY CERTIFY THAT THE ABOVE INFORMATION ARE CORRECT TO THE BEST OF MY OF CLAIMANTBIR TAX ACCOUNT NUMBERPREVIOUS EMPLOYERS (IF ANY)ADDRESSINCLUSIVE PERIODS OF employment (TO BE FILLED IN BY CLAIMANT)ACKNOWLEDGEMENT RECEIPTSICKNESS CLAIM INDEX CARDFROM: SOCIAL SECURITY SYSTEM, QUEZON CITYTO: POSTMASTERNAME OF CLAIMANTSS DELIVER THIS RECEIPT TOCLAIMANTADDRESSADDRESSCONFINEMENT PERIOD(EXACT DATES)FROMTODO NOT FILLFOR SSS USECLAIM FILEDCLAIM FILEDRECEIVED BYRECEIVED BYSICKNESS BENEFIT APPLICATION form (FOR UNEMPLOYED/SELF-EMPLOYED/VOLUNTARY MEMBERS)SSS form CLD-9 ARepublic of the PhilippinesSOCIAL SECURITY SYSTEMSOCIAL SECURITY SYSTEMSOCIAL SECURITY SYSTEMSOCIAL SECURITY SYSTEMSOCIAL SECURITY
when there is a case pending before a court regarding separation of the claimant. The following table shows the document required for any of these cases: CONDITION DOCUMENT REQUIRED a. Company on strike Certification from CIR or Department of Labor and Employment b. Company dissolved or closed Affidavit by the claimant to this effect
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