Transcription of SICKNESS BENEFIT APPLICATION FORM
1 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.
2 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 SYSTEMI nternet Edition (7/2000) only one (1) copy. Avoid erasures or personally filed, submit this SSS form directly to the SSS Medical Evaluation confined member is a married woman, print reported name at in the dates required in the format Month-- Day-- of separation is not necessary when the company is on strike, dissolved or closed, orwhen there is a case pending before a court regarding separation of the claimant. The following tableshows the document required for any of these cases:CONDITIONDOCUMENT on strikeCertification from CIR or Department of Labor dissolved or closedAffidavit by the claimant to this case before a courtCertification from the 12-month period where to select the six highest Salary Credits:Example:CONFINEMENTPERIODJ anuary to March 1998 October 1996 to September 1997 April to June 1998 January 1997 to December 1997 July to September 1998 April 1997 to March 1998 October to December 1998 July 1997 to June 1998
