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Republic of the Philippines SOCIAL SECURITY SYSTEM MATERNITY BENEFIT APPLICATION ‘SIC-01249 (122018) (FOR SELF-EMPLOYEDIVOLUNTARY MEMBER OR MEMBER SEPARATED FROM EMPLOYMENT) N “THis FORW WAY BE REPRODUCED AND 18 NOT FOR SALE. THIS GAN ALSO BE DOWNLOADED THRU THE SSS WEBSITE AT wewrsvngoveh. PLEASE READ THE INSTRUCTIONS AT THE BAGK BEFORE FILING OUT THIS FORM PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK PARTI TO BE FILLED OUT BY MEMBER. TPERSORACOATE pe es eA Be Pf rae ae arb Lb Leber LOCAL RODRESS —___- SEE aT ea] oe EP FOREIGN ADDRESS arco GoONTAY FCoE FOR SEPARATEDIVOLUNTARY MENGER, PLEASE INDICATE THE FOLLOWING: Name of iat employer Date of separation from ast employer [START OF MATERNITY LEAVE [DATE OF DELIVERY [DIAGNOSIS [ype of calverymscariapeprocedurs) INOMGER OF PREGRANGES Jrwcore ImiscARRIAGE/PROCEDURE lomoorrry) Dermat C1 miscarriage C1 Ectople (Operated) Dcacsarean C1 Hale Ectopic vnoperates 'B. MEMBER'S ENROLLMENT IN THE PAYMENT THRU THE BANK (not yet enrolled) [BANE WANE AND BRANCH IGANK BRANCH ADDRESS jz cove BANE ACCOUNT WANE SANK ACCOUNT NUMBER Cisavinesicurrent account Clumioatmaccount C1 CASH CARD VALIO UNTIL ‘CCERTIFICATION Tari tat the information provided in this form are tue and correct PRINTED NAME ‘SIGNATURE DATE I member cannot sign, affix ngerprints, Please read Instruction No.6 ofthe form, Below are the witnesses to fingerprinting = een aonb iS Shieh PRINTED NAME ‘SIGNATURE DATE [ADDRESS & CONTACT NUMBER 2 PRINTED NAME a ADDRESS & CONTACT NUMBER RIGHT THUMB RIGHT INDEX: TREASON FOR EXEMPTION FROW THE PROGRAM Tr iWembars amount of benefits one thousand pesos (P1,000) and below. i Members address is beyond 30 kms tothe nearest SSS-accredited bank 5 Members address isin high risk area. 5 Member i physically incapable of transacting business with the bank fence Sec are [SCREENED AND ENCODED BY lReveweo ov ‘SIGNATURE OVER PRINTED RANE DATE THe ‘BRANCH HEAD DATE SIGNATURE OVER PRINTED NAME ce SOCAL SECURITY SYSTEM MATERNITY BENEFIT APPLICATION ACKNOWLEDGEMENT STUB N eae ee eae ei eee as EW aa | DRTE OF DELIVERY! RECEIVED BY IscaRRAGEPROCEDURE "SIGNATURE OVER PRINTED WANE. DATES TE ‘Verftcation of satus of Gaim may be made tu the SSS Website at www see gov ph or contact our Cal Centar al 205446 10 5S. 10. 2. Maternity Notification INSTRUCTIONS Fill out this form in one 1) copy. ‘Always indicate "NIA or “Not Applicable’, if the required data is not ‘applicable ‘Af initials on all aterationsierasures inthis form. ‘Wate SS Number and name of member in all he supporting documents ‘submitted Present valid identification cars or documents. Refer tothe attached “Ust of Filer’ Vald Identfcation (1D) Cards/Documents” member cannot sign, witnesses to fingerprinting shall be a fllows: Filed by member ‘SSS receiving personnel who shall affix his/her signature on the space provided and shall indicate employee number and branch on the “Address and Contact Number portions provided in Part -C. member’ i Two (2) winesses. One (1) witness is the member's representative and the other one (1) could be any person. Both should affix th Signatures and indicate their addresses and contact numbers on the pation provided in Pat IC. ‘Accomplish Part -B of this form, if nt yet enroled in the Payment thry the Bank Program, ‘Secure Letter of Introduction (LO! form ftom SSS, if without existing bank accounts, which shall be presented to the S$S-accredited bank chosen by the member for purposes of opening of single savings faccountieash card account ‘Submit photocopy of any ofthe folowing bank document, whichever is ‘applicable, to ascertain correcness of bank account information: ‘+ ATM Card (wth account number) ‘Bank Account Passbook + Bank StatementiCentfeate + Depost Slip'Savings account number cara Maternity beneft payments shall be remited by the SSS to members ‘designated bank ‘Submit this form to the nearest SSS branch office together with the following supporting documents, whichever is applicable (UN) duly received by SSS prior to delveryimiscaragelprocedure or "Maternty Notification Submission Confirmation’ (fed thru the SSS Website or SSIT) Note: MN is not requited it the member deliveredwas confined in a hospital duly icensed by the Department of Heath », Required Documents resent the orginallcrtifed true copy and submit the photocopy of the folowing, whichever is appicabe 1 EorNomal Delivery * Chis bith or fetal death cortiicate duly registered with the Local Givi Registrar (LCR) 2 For Caesarean Delvery ‘+ Chis bith or fetal death certiicate duly registered with the ck); and ‘+ Any of the following documents issued by the hospital indicating the type of delivery Operating Room Record (ORR) Surgical Memorandum Discharge Summary Report MedicalCinical Abstract Delivery Report Detaled invoice showing caesarean delivery charges, for deliveries abroad only 3 For Compl riage * Obstetrical History indicating the numberof pregnancies duly cettiod by attending physician with hisiher Professional Medical License Number with printed name and signature; and ‘Any ofthe following: Pregnancy test before and after miscarriage % Ubasound report indicating proof of pregnancy ¥ Medical Certfeate issued by attending physician on the ccreumstances of pregnancy 4 FocIncomplete Miscariage * Obstetrical Histor incleating the number of pregnancies uly cetiied by attending physician wih his/her Professional ‘Medical License Number with printed name and signature; and ‘Any ofthe flowing Certified true copy of HosptalMedical records Dilation & Curettage (0 & C) report Histopathologial report Pregnancy test before and ater miscariage Utrasound report indicating proof of pregnancy v5 ForEctonie Presnancy + Obstetrical History indicating the number of pregnancies duly cettfed by attending physician with hisiher Professional Medical License Number with printed name and signature; and + Any of the folowing: 7" Cetifed true copy of HospitalMedical records ¥ Gerted true copy of ORR. % Histopathological report Pregnancy test before and after miscariage 26 For Hydatdforn Mole Allo the fliwing ‘+ Obstetrical History indicating the number of pregnancies duly Certied by attending physician wth hisier_ Professional ‘Medical License Number with printed name and signature + D&C report + Histophathological report, Note: The Medical Specialist may require other documents necessary for the evaluation of the claim (fr miscariage! ectopiclH-Mote cases) «Additonal Required Documents Present the originafcetifed true copy and submit the photocopy of the following, whichever is applicable: 1 For Sett-Employed/Voluntary Member (previously employed) ldelveryimiscar sti 7 months from date of separation + Certificate of separation from employment with effective date of separation and no advance payment was granted (signed by the employer's authorized signatory reflecied in SS Form Usotp 62. For Member Separated from Employment I deliveryimiscarriage/procedure is within employment period ‘+ Certificate of separation from employment wih effective date of separation and no advance payment was granted (signed by the employer's authorized signatory reflected in SS Form L501) tdelveryimiscariage/oroceduce i afer date of separation * Certificate of separation from employment with effective dte ‘of separation signed by the employer's authorized signatory reflected in SS Form L-501) CCerticate of separation is not required for selt-employedivoluntary member (previously employed) of member separated from ‘employment under ary” of ‘the folowing conditions in which ‘supporting documents’ shall be required to be submited as ‘enumerated below ‘company ison strike + Notice of strike duly acknowledged by the DOLE: and + Duly notarized Affidavit of Undertaking issued by the member ‘that no advanced payment was granted company hi ved or + Duly notarized Affidavit of Undertaking issued by the member that! no advance payment was granted and with indicated effective date of separation lWthere is @ case pending before a cour regarding separation of member = Cettfication from DOLE: and ‘+ Duly notarized Affidavit of Undertaking issued by the member that no advance payment was granted and with indicated effective date of separation selatons witthe employer ‘Duly notarized Affidavit of Undertaking issued by the member that no advance payment was granted and with indicated reason and effective date of separation Note: For delveriesimiscarriagesiprocedure that happened abroad, ‘documents issued by foreign county should be wih English translation and duly authenticated by the Philppine Embassy! Consulate Office or duly notarized by notary pubic in host ‘county 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 SECTION 28 OF RA 8282 OR UNDER PERTINENT PROVISION OF WARNING REVISED PENAL CODE. SS i INANE OF WENEER a PART Ill. TO BE FILLED OUT BY S85 “E-BRANCH OFFICE [SCREENING AND RECEIVING RESULTS. REMARKS lors Presenes by er CSS Card C2 Vals 0 Caras or Documeris D0 None Fam Accomplanment ) Complete C2) incomplete (ne eats) occuments Submited C1 Complete incomplete (ee ears) igeity Rest cussed Not GuatfedDeniedntnsscropanylies (serena) |SCREENED AND RECEIVED BY ‘SIGNATURE OVER PRINTED NAME DATE THe oaTa ETO) SCREENING AND RECENING RESULTS FOR REFILED CLANS peau 1D cia scented Ci cis nt accepted (ne ema) SCREENED AND RECEIVED BY "SIGNATURE OVER PRINTED NAME DATE Tae DATE RETURNED 3. MEDICAL EVALUATION ‘SECTION (FOR MISCARRIAGE CASES) fciness cone Jomcnoss [RECOMMENDATION 1 Asproved No.of Days 1 denies TR D5 pregnancy not compensable Cl Retwned tor Compliance 1 Based on histopathresut, pregnancy not confmed 1 siomt 0 &¢ report Based on utresouna result. pregnancy not contmed G1 submit operating Room Record (ORR) Ci remarks G swomthstopsthloges! reaut 1 Peneing G1 Sut pregnancy result etre and ter misariage) Cl Formediaropmon Gi suet tratound resut Gi Fer document verifeation Gi Suen compete OB Histor isued by attending physician Di Fotegal pion Gi Feorinterviow & present SS Card or Val 10 Cards or Documertis Ci remars Bi Remarks RECEIVED BY (NITIAL FILING) EVALUATED BY SIGNATURE OVER PRINTED NAME DATE ‘SIGNATURE OVER PRINTED NAME DATE RECENED BY (REFILED CLAM) JEVALUATED BY ‘SIGNATURE OVER PRINTED NAME DATE ‘SIGNATURE OVER PRINTED NAME DATE “C. PROCESSING CENTER [FOR NAL UNG [PROCESSING RESULTS JReceiven ey |pRoCESSED AND ENCODED BY “SIGNATURE OVER PRINTED NAME DATE ‘SIGNATURE OVER PRINTED NAME DATE REVIEW RESULTS [CONCURRED BY 1D Approves C Reectes Coens Revieweo ey “SIGNATURE OVER PRINTED NAME DATE ‘SIGNATURE OVER PRINTED NAME DATE [FOR REFLED CLAM) PROCESSING RESULTS RECEIVED BY PROCESSED AND ENCODED BY ‘SIGNATURE OVER PRINTED NAME DATE ‘SIGNATURE OVER PRINTED NAME DATE IREVEW RESULTS [CONCURRED BY ID Aoprovea I Rejectes IB denies JRevieweo oy ‘SIGNATURE OVER PRINTED NAME DATE ‘SIGNATURE OVER PRINTED NAME DATE