V. LIST OF REQUIREMENTS

V. LIST OF REQUIREMENTS ... documents issued by foreign country should be in English ... Business Permit/Registration of Business Name or any proof of...

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EMPLOYEES’ COMPENSATION COMMISSION

V.

CITIZEN’S CHARTER

LIST OF REQUIREMENTS

A. DOCUMENTARY REQUIREMENTS IN FILING EC Claim at the GSIS 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. Duly accomplished Form for Hospital/Clinical records of confinement/consultation due to claimed ailment d. Service Record, if claimant is uniformed personnel of AFP, PNP, BJMP and BFP 2. Injury a. Duly accomplished Form for Sickness Income Benefit Claim for Payment, Part I and II b. Duly accomplished Form for Hospitalization Claim for Payment, Parts I, II, and III c. Duly accomplished Form for Hospital/Clinical records of confinement/consultation due to claimed ailment d. Certification under oath by Head of Office narrating in detail the circumstances surrounding the accident (e.g. time, date and place of accident and what employee was doing at the time of accident and reason or purpose of being there) e. Service Record, if claimant is uniformed personnel of AFP, PNP, BJMP and BFP f. Affidavit of witnesses to the accident/incident g. Time Card/Record of Attendance h. Police Accident/Investigation Report i. Travel/Mission Order/Personnel Pass j. Casualty Report/After Battle Report/Line of Duty Board Proceedings for AFP members k. NAPOLCOM Adjudication Award for PNP members 3. Death Claim a. With primary beneficiary/ies 1) Death Certificate of member issued by NSO 2) Marriage Contract of member issued by NSO 3) Birth Certificate of member for uniformed personnel of AFP, PNP, BFP and BJMP issued by NSO 4) Birth Certificate of legitimate minor/incapacitated children, 21 years old and below issued by NSO 5) Birth Certificate of spouse issued by NSO, if not a GSIS member 6) Affidavit of Surviving Spouse With Declaration of No Remarriage 7) If with minor children, Affidavit of Legal/Certified Guardianship Form for minor dependent child 8) If with incapacitated children, Affidavit of Legal/Certified Guardianship Form for incapacitated dependent child 9) If the guardian is not the natural parent, Court Order or Affidavit of Guardianship Form supported by DSWD and Barangay Certification where the minor/incapacitated dependent child is residing b. Secondary beneficiaries (parents and illegitimate children) a) Death Certificate of member issued by NSO b) Birth Certificate of member issued by NSO c) If parents are not GSIS member/pensioner, Birth Certificate issued by NSO d) Birth Certificate of illegitimate children 21 years old and below issued by NSO 4/F - 5/F ECC Bldg., 355 Sen. Gil J. Puyat Avenue, Makati City v16.1 (Date updated: September 15, 2016)

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e) Affidavit of parents that member died single with or without illegitimate children and that they are wholly dependent upon the deceased for support f) Death certificate of parents, if deceased g) If with minor children, Affidavit of Legal/Certified Guardianship Form for minor dependent child h) If with incapacitated children, Affidavit of Legal/Certified Guardianship Form for incapacitated dependent child i) If the guardian is not the natural parent, Court Order or Affidavit of Guardianship Form supported by DSWD and Barangay Certification where the minor/incapacitated dependent child is residing 4. Death of a PTD Pensioner (Transfer of Pension) a. Death Certificate of member-pensioner issued by NSO or equivalent certification from the foreign country where the pensioner died, authenticated by the concerned embassy b. Duly accomplished Application Form for Income Benefit Claim for Payment, Part I only c. Additional documents shall be required if after evaluation the spouse and/or the legal heirs are found to be qualified for pension. 1) Marriage Contract of deceased pensioner with the claimant issued by NSO 2) Affidavit of Surviving Spouse With Declaration of No Remarriage 3) If spouse is not a GSIS member, Birth Certificate issued by NSO 4) Birth Certificate/s of minor/incapacitated children issued by NSO 5) If with minor children, Affidavit of Legal/Certified Guardianship Form for minor dependent child 6) If with incapacitated children, Affidavit of Legal/Certified Guardianship Form for incapacitated dependent child 7) If the guardian is not the natural parent, Court Order or Affidavit of Guardianship Form supported by DSWD and Barangay Certification where the minor/incapacitated dependent child is residing B. DOCUMENTARY REQUIREMENTS IN FILING EC Claim at the SSS 1. Sickness claim a. Sickness Notification b. Sickness Benefit Reimbursement Application c. Approved Sickness Notification (SN) or Certificate of Medical Approval issued by the Medical Evaluation Section d. Accident/Sickness Report e. Police Report (for vehicular accident with third party involvement) f. Copy of page of EC Logbook (manual logbook or electronic filing) for approved EC claim g. Filer’s SS card or other valid IDs/documents h. Medical documents, if any

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Filed by Employer (Business/Household) Present the original of any one (1) of the Employer’s primary ID cards/documents or two (2) secondary ID cards, both with signature and at least one (!) with photo. Filed by Company Representative Present the Authorized Company Representative (ACR) Card, or if without ACR card (not available at the time of filing), present the following:  Letter of Authorization (LOA) issued by the employer’s authorized signatory reflected in the Employer Specimen Signature Card (SS-Form L-501)  Original company ID of company representative Filed by Employer Representative  

LOA issued by the employer’s authorized signatory reflected in the SS Form L-501 Original company ID of employer representative Note: For EC benefits claim, fill out Part IIB of the Sickness Benefits Reimbursement Application Medical Specialist shall determine required documents based on a separate checklist. For sickness/injury acquired abroad, documents issued by foreign country should be in English translation and must be authenticated by the Philippine Embassy Consulate Officer or duly notarized by a notary public from the host country.

2. Disability claim a. Disability Claim Application (DisCA) form b. Member’s/Claimant’s Photo and Signature Form (for initial claims only) c. SSS Medical Certificate Form accomplished by attending physician d. Medical records e. Photocopy of SS cards, Passport, Alien Resident Certificate Medical Specialist shall decide if additional medical records/documents will be required. 3. Funeral claim a. Funeral Claim Application Form  Filer’s Affidavit b. Proof to establish SSS membership of deceased member (present any one (1) of the following:  Social Security (SS) Card/Unified Multi-Purpose ID (UMID) card  Duly received SS Form E-4/Contributions Collection List (R-3)/validated Contributions Payment (RS-5)/Member Loan Payment (ML-1), SS Form E-1/RS-1/NW-1/OW-1  Employment Record with member’s SS Number (e.g. company ID, payslip)  Letter/Certification document with indicated correct SS Number previously issued by the SSS prior to the death of the member

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In the absence of the Proof to establish SSS Membership, any one (1) of the following documents may be presented as reference for the verification of the deceased member’s SSS membership:          

Birth Certificate Baptismal Certificate Marriage Contract/Certificate Philippine Health Insurance Corporation (PHIC) Member’s Data Form Home Development Mutual Fund (Pag-IBIG) Member’s Data Form BIR Form GSIS Member’s record Life Insurance Claim School Records Business Permit/Registration of Business Name or any proof of business operations

Claimant’s Identification Cards/Documents (Present the original and submit photocopy) Any one (1) of the ID cards/documents considered as primary IDs In the absence of a primary ID cards/documents, any two (2) of the ID cards considered as secondary ID cards/documents (original) both with signature and at least one (1) with photo. c. Death Certificate of deceased member (Present the original/duplicate/certified true copy/certified photocopy and submit photocopy) If member was buried/cremated in the Philippines—Any one (1) of the following:  Death Certificate duly registered with the Local Civil Registry Office (LCR) and signed by the authorized signatory of the Office of the Civil Registry  Death Certificate issued by the Philippine Statistics Authority (PSA)  Certification of Death of deceased member issued and signed by the authorized signatory of the Office of the Civil Registry and bearing the official seal In the absence of the above-mentioned documents, submit the following:  

Certification of non-availability issued by LCR and PSA; and Any one (1) of the following: o Certification of Death issued by the Parish/Church o Certification of Burial issued by the Cemetery Administrator o Certification of Cremation

Late registered Death Certificate shall be accepted provided the following information/features are present:   

Registry Number Name and signature of authorized signatory of the Office of Civil Registry Date of Receipt by the LCR/PSA

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 

CITIZEN’S CHARTER

Properly filled-out affidavit at the back of the Death Certificate explaining the reason for the delay Without erasures, alterations, insertions, and super impositions

d. Official Receipt (OR) with BIR registration bearing the name of the claimant and the deceased member (submit original copy) If the name of the claimant is not indicated in the OR, submit additional document below:  Waiver/Pagpapaubaya If original OR is not available (e.g. lost, original copy submitted to other agency), submit any of the documents below:  

Certified true copy of OR Certification issued by the funeral parlor/memorial service indicating the details of payment in defrayal of funeral expenses of the deceased member

If the OR is not yet available and not yet buried, submit the document below: 

Funeral service contract issued by the funeral parlor

If the OR is not yet available and payment not yet fully settled, submit the document 

below:

Provisional Receipt

e. In lieu of Official Receipt (Submit original receipt) If Memorial/Insurance Plan was in the name of the deceased member, submit the document below: (for preferred beneficiary only)  Certification of Availment from the memorial/insurance life plan company If Memorial/insurance Plan was in the name of the claimant, submit the document below: 

Certification of Availment from the memorial/insurance life plan company indicating the name of the deceased member, claimant, and date of death

If the name of deceased member is not indicated in the certification of availment, submit the additional document below: 

Affidavit executed by the plan holder allowing the use of the memorial/insurance plan by the deceased member

If Memorial/Insurance Plan was not in the name of the deceased member and claimant, submit the documents below:  

Certification of Availment from the Memorial/Insurance Life Plan company: and Any one (1) of the following whichever is applicable: - Transfer Certificate - Deed of Sale

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- Deed of Donation - Affidavit of Sale executed by the plan holder For funeral expenses incurred without corresponding OR/contract, submit the (for preferred beneficiary only) 

document below

Duly notarized Affidavit (Funeral Expenses)/Sinumpaang Salaysay (Pinagbayaran sa Pagpapalibing)

Additional/Other Required Documents 1. If cause of death is a work-related accident: a. Accident Report/Report of Death (SS Form BPN-105) b. Statement of Duties and Responsibilities c. Updated Service Record d. Police investigation report or employer’s report of injury, death, or casualty spot report, when applicable e. Mission/Job or Travel Order, when applicable f. Photocopy of page in the EC Logbook/record of accident signed by the employer 2. If cause of death is a work-related sickness: a. Accident/Report of Death b. Statement of Duties and Responsibilities c. Photocopy of page in the company logbook/record of accident signed by the employer d. Pre-employment medical record 4. Death Claim a. Death Claim Application (DCA) Form b. Member’s/Claimant’s Photo and Signature Form c. Filer’s Affidavit (Sinumpaang Salaysay) - Only one Filer’s Affidavit is required at the time of filing d. Form CLD-1.3A, Affidavit of Death Benefit (if claimants are primary or secondary - Only one CLD1.3A is required at the time of filing e. Any one of the following, whichever is applicable - Form CLD 1.3, Joint Affidavit of two (2) disinterested persons, preferable relatives of the deceased member, if claimants are designated beneficiaries of legal heirs of deceased member i. Only one CLD1.3 is required at the time of filing - Form CLD-15 Application for Appointment as Representative Payee, if claimant is a guardian - Form BPN-107, Guarantor’s Bond Form, if claimant is a guardian - Report of Death (BPN-105) - Pre-employment medical records, if cause of death is due to illness - Statement of duties and responsibilities duly signed by the employer - Mission/Job or travel order duly signed by the employer, when applicable - Photocopy of page in the company logbook/record of accident signed by the employer - Police investigation report or employer’s report of injury, death, or casualty spot report, when applicable

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Joint Affidavit (preferably by the relatives of deceased member) that the deceased and the common-law spouse have no legal impediment to marry, if with dependent illegitimate children

f.

Single savings account passbook/ATM card/validated initial deposit slip/accomplished visa cash card enrollment form, if pension g. If the account number is not reflected in the ATM card, or if the name of the spouse/claimant is not embossed in the ATM card or it is not yet available, a copy of initial deposit slip shall be required. h. If spouse/claimant cannot open a savings account passbook or apply for visa cash card, a written request for exemption from Pensioner Remittance Program indicating the reason/s for the request shall be required i. In-Trust-For (ITF) account, if claimant is under guardianship j. Pro-forma-affidavit attesting dependency for support (if dependent-parent/s) k. Written explanation, if death claim was filed by spouse beyond 5 years from date of death Identification Documents a. Any of the valid primary IDs b. In the absence of a valid primary ID, any two (2) of the valid secondary IDs (original) both with signature and at least one with photo c. Or, in the absence of a valid primary ID, any one (1) of the valid secondary IDs (original) with signature and photo and at least one (1) of the valid secondary documents Supporting Documents a. Certified true copy of death certificate of deceased member duly registered with the Local Civil Registry (LCR) and signed by the authorized signatory of the Office of the Civil Registrar or Philippine Statistics Authority (PSA) Primary Beneficiaries Spouse and Dependent Legitimate/Legitimated, Legally Adopted and Illegitimate Dependent Child/Children b. Certified true copy of marriage contract/certificate of deceased member duly registered with LCR/PSA c. Certified true copy of birth certificate of dependent child/children duly registered with LCR/PSA Secondary Beneficiaries Dependent Parents d. Certified true copy of birth certificate of deceased member duly registered with LCR and signed by the Civil Registrar or PSA e. Proofs of dependency upon the deceased member A.

Primary ID Cards/Documents 1. Social Security (SS) cards 2. Unified Multi-Purpose ID (UMID) 3. Passport

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B.

CITIZEN’S CHARTER

4. Professional Regulation Commission (PRC) card 5. Seaman’s Book (Seafarer’s Identification and Record Book) Secondary ID Card/Documents 1. Alien Certificate of Registration 2. ATM Card (with cardholders name) 3. Bank Account/Passbook 4. Company ID card 5. Certificate of Confirmation issued by the National Commission on Indigenous People 6. Certificate of Licensure/Qualification Documents from Maritime Industry Authority 7. Certificate of Naturalization 8. Credit Card 9. Court Order granting petition for change of name or date of birth 10. Driver’s License 11. Firearm License Card issued by the Philippine National Police 12. Fishworker’s License issued by the Bureau of Fisheries and Aquatic Resources (BFAR) 13. Government Service Insurance System (GSIS) card/Member’s Record/Certificate of Membership 14. Health or Medical Card 15. Home Development Mutual Fund (Pag-IBIG) Transaction Card/Member’s Data Form 16. ID card issued by the Local Government Units (LGUs) 17. ID card issued by professional association recognized by PRC 18. Life Insurance Policy of member 19. Marriage Contract/Marriage Certificate 20. National Bureau of Investigation (NBI) Clearance 21. Overseas Worker Welfare Administration (OWWA) card 22. Philippine Health Insurance Corporate (PHIC) ID card/Member’s Data Record 23. Police Clearance 24. Postal ID Card 25. School ID Card 26. Seafarers Registration Certificate issued by the Philippine Overseas Employment Administration (POEA) 27. Senior Citizens card 28. Student Permit issued by the Land Transportation Office (LTO) 29. Taxpayer Identification Number (TIN) card 30. Transcript of Records 31. Voter’s Identification card or Voter’s Affidavit

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