Republic of the Phil SOCIAL SECURITY SYSTEM SICKNESS BENEFIT REIMBURSEMENT APPLICATION SIC 01253 (12-2015 "THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE, THIS CAN ALSO BE DOWNLOADED THRU THE SES.NEBSITE AT WWW.SSS,0OV.PH ‘LEASE READ INSTRUCTIONS AND REMINDERS AT THE BAK BEFORE FILLING QUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK. INK ONLY 5 FSSnoWeER COMMON REFERENCE WO Ses a aoa iE pa P| EP pent oe LE PE a rae Tara aSTTA EaEN) Fe [LOCAL ADDRESS “FIFLRIT RO BLOG TET TOURETTE MR ROT STREET Way 4 RTT SST FREE TORE EP CODE Li HELEPTONE NO amen coor EL nay | WOBTCEICELLPHIONE NO, EMAL ADDRESS ee ene ererenererer ene FOREIGN ADDRESS prarecann EOONTAY EP CODE TERT TAT 2) The noaton proved a tae ec nd 5) Lacuol caved he amour of brat do as nated Paoli om, (De no sgn the amounts nt actualy advanced) FRED WE SERATORE ONE 1f member cannot sig, ax fingerprints. Please red instruction No.6 atthe bac ofthe form Blow are the wtreses to ingorpintin » FARTS TRAE oH 2 Fae sionarune OE ADoRESS CONTACT HUMBER eT TorTeeT SoH [SICKNESS BENEFIT TYPE Ty SOCIAL SECURITY ($8) TT EMPLOYEES COMPENSATION (EC) EMPLOYER WUMBER FAK IDENTIFICATION NUMBER FVPE OF EMPLOYER tp |) 1 eainns Den ERPCOVER WANE ERPLGVER ROORESS AAR TOTS TERE TOES ara RTT a etal HELEBHONE WO amen coe Ta oy — EMAIL ADDRESS WEBSITE (or business emptor Peet TPPROVED ORF NEMENT PERIOD TORR FAS ER TRIBE BR [START wmoovYYY) TEND (aNNDDYYYY) ic | ||) [COMPANY STCRLEAVE pen Apsense oo IC empoyee nas exnsused a cuert company scxeave wth py: D1 Employee retumed to work on B Employee stil on eave/nat yet reporting Gi Employ su nas _company sk ave (SL) wah pay for ne cure yor ‘SOCIAL SECURITY (55) EMPLOYEES" COMPENSATION (EC) ait Wy Satay roa THC) Divdecy 180 ‘Average Day Say Crest (ADSC) Mp by 0% Daly Sines Atowance (054) tip by soproved na, day (ss SL any) Tawny Saany reat TSC) vated by 180 [average Dat Stary Creat (ADS) rate y 0% Dat SictnessAtowarce (OSA) ast by approved no. ot ays Jancuctt Benet ue he Member © EMPLOYER'S CERTIFICATION THIS 1S TO CERTIFY THAT 8) The formation provided ae true and corec; b) The qualifying contrbutions of member were pad prior othe date of sickness/inury; and ©) The amount of benef de as Indicated above was advanced to the employee. ‘SIGHATURE OVER PRINTED NAME ENPLOYER/AUTHORIZED REPRESENTATIVE ‘OFFIGIAL DESIGNATION DATE rate Hore ‘SOCIAL SECURITY SYSTEM SICKNESS BENEFIT REIMBURSEMENT APPLICATION ACKNOWLEDGEMENT STUB <4 5 NUMBERICRN (FAW) PSL ea [evant oF eNERS IREceveD ey ‘SIGNATURE OVER PRINTED NAME: DATE & TIME: SSS BRANCHH BRANCH OFFICE SGREEIING AD RECEIVING RESULTS Romans os Presenied by tet. CJACR Card CI Co, authorization eter and company 10 Osscard ©) Valid '0/s [1] None ror sczonptshnent: E} Complete [ical mat) [Documents Submitted: [] Complete [[] Incomplete (see remarks) eign Reso) Qvelfes Cy Not Quaid DenedWah dscepencies (eras) Jscneenen ano RECEIVED BY | ‘SIGNATURE OVER PRINTED NAME DATE: TIME DATE RETURNED [SCREENING AND RECENNG RESULTS FOR REFILED CLAIMS Romans 1 claim accepted Gi Clair not accepted 08 remarks) SCREENED AND RECEIVED BY SIGRATURE OVER PRINTED NAME DATE THe, DATE RETURNED, FOR NTAL FUNG PROCESSING REST recenven ev lpROCESSED AND ENCODED BY SIGNATURE OVER PRINTED NAME DATE SIGNATURE OVER PRINTED NAME DATE [Review ResucT |CONGURRED BY D1 Approved Di Rejected Denes Reveweo ov SIGNATURE OVER PRINTED NAME DATE SIGNATURE OVER PRINTED NAME DATE FOR REFLED CLAM [PROCESSING RESULT RECEWvED BY lpROCESSED AND ENCODED BY SIGNATURE OVER PRINTED NAME DATE: ‘SIGNATURE OVER PRINTED NAME DATE REVIEW RESULT [CONCURRED BY i Approved Ty Rejectes Denies IREVIEWED BY SIGHATURE OVER PRINTED RANE SIGHATURE OVER PRINTED NANE {STRUCTIONS AND REMINDERS 1. Fill out this form in one (1) copy. If member is entitled o SS and EC sickness benef, flout Pat IB ofthis frm forthe computation ofboth benefits 2. Always indicate "NIA" or "Not Applicable’, the required datas not applicable 3. Wiite $$ number and name of member in all documents fr submission, ‘4. Attach anginal copy of approved Slcknesss Notification tothe Sickness Benefit Reimbursement Application, 5. Present valid identfcation cardsidocuments. Refer to attached List of Fler’ Valid Identification ((D) Cards/Documents, 6. member cannot sign, there should be two (2 witnesses fo frgerprining. One (1) winess isthe employer representaielcompary representative andthe ‘other one (1) could be any person 7. The employer shall advance the amount of benef due the member upon receipt of he approved sickness notification from SSS, 8. Any alteration must be iniled by the member or the empoyerlauhorized company representative, 8. This form can also be downloaded thru the SSS website (www. s8s.90v ph). ‘Qualifying Conditions Soctal Security (88) Employees! Compensation (EC) Inumum number of days for hospal orhome [ATeas aye aay Jeonfnement [Guathjing contibutons Paid at east 3 monty contibutone witin the 12 | day of employment le covered for work vated |month period immediately preceding the semester of _|sicknessinjuy sicknessinixy [Garpany sick eave (SL) wih pay [Exhaust al company SL forthe ourenk year [Need not exhaust company SU wih pay Prescriptive porod of fing reimbursement |For home confinement the dain for reimbursement by [Three (3) years Fam the dale of sicknessTinary ine empioyer must be fled within one (1) year immediately ater the start of iness. |For hospital confinement, must be fled within one (1) year from the last day of confinement in such hospital 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 SEC, 8 OF RA 8282 OF THE SS LAW OR UNDER PERTINENT PROVISIONS OF REVISED PENAL CODE AND ART, 297 () CHAPTER Ix OF PD 626 as Amended)>| LIST OF FILER’S VALID IDENTIFICATION (ID) CARDS/DOCUMENTS Sickness Benefit Reimbursement Process Primary ID Cards/Documents eaens Social Security (SS) card Unified Multi-Purpose ID (UMID) card Passport Professional Regulation Commission (PRC) card ‘Seaman's Book (Seafarer's Identification & Record Book) Secondary 1 CardsiDocuments 27. 29 30. 34 ‘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 Souther Cultural Community and Office of Northern Cultural Community) Certificate of Licensure/Qualification Documents from Maritime Industry Authority Certificate of Naturalization Credit card Court Order granting petition for change of name or date of birth Driver's License Firearm License card issued by Philippine National Police (PNP) Fishworker’s License issued by Bureau of Fisheries and Aquatic Resources (BFAR) Goverment Service Insurance System (GSIS) card/Member's Record/Certificate of Membership Health or Medical card Home Development Mutual Fund (Pag-1BIG) Transaction Card/Member's Data Form ID card issued by Local Goverment Units (LGUs) (e.g. Barangay/Municipality/City) ID card issued by professional association recognized by PRC Life Insurance Policy of member Marriage Contract/Marriage Certificate National Bureau of Investigation (NBI) Clearance ‘Overseas Worker Welfare Administration (OWWA) card Philippine Health Insurance Corporation (PHIC) ID card/Member’s Data Record Police Clearance Postal ID card ‘School ID card Seafarer’s Registration Certificate issued by Philippine Overseas Employment Administration (POEA) Senior Citizen card Student Permit issued by Land Transportation Office (LT0) Taxpayer's Identification Number (TIN) card Transcript of Records Voter's Identification card or Voter's Affidavit / Certificate of Registration 7. Filed by Employer (Business/Housohoid) Present the original of any one (1) of the Employer's primary ID cards/documents in tem A or two (2) ‘secondary ID cards/documents in Item B both with Signature and at least one (1) with photo. Filed by Company Representative Present the Authorized Company Representative (ACR) Card_or if without ACR Card (not available at the time of fling) present the following: 2.1, Letter of Authorization (LOA) issued by the ‘employer's authorized signatory reflected in the Employer Specimen Signature Card (SS Form L501); and 22 ID Original company of representative, company 3. Filed by Employer Representative 3.1 LOA issued by the employer's authorized signatory reflected in the SS Form L-01 3.2. Original company 1D of _—_ employer. representative,