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
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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
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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 DATELIST OF FILER’S VALID IDENTIFICATION (ID) CARDS/DOCUMENTS.
Maternity Benefits Process
zw
Primary ID Cards/Documents
1. Social Security (SS) card
2. Unified Multi-Purpose ID (UMID) card
3. Passport
4.
5.
Professional Regulation Commission (PRC) card
‘Seaman's Book (Seafarer's Identification & Record
Book)
‘Secondary ID Cards/Documents
1. Alien Certificate of Registration
2, ATM card (with cardholder's name)
3. Bank Account Passbook
4, Company ID card
5. Certificate of Confirmation issued by National
Commission on Indigenous People (formerly Office of
Southern Cultural Community and Office of Northern
Cultural Community)
6. 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
410. Driver's License
11, Firearm License card issued by Philippine National
Police (PNP)
Fishworker’s License issued by Bureau of Fisheries
and Aquatic Resources (BFAR)
Government Service Insurance System (GSIS)
card/Member's Record/Certificate of Membership
414, Health or Medical card
15. Home Development Mutual Fund (Pag-IBIG)
Transaction Card/Member's Data Form
16. ID card issued by Local Government Units (LGUs)
(e.g, Barangay/Municipalty/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
31. Voter's Identification card or Voter's Affidavit
Certificate of Registration
12
18.
1. Filed by Member
Present original of any one (1) of the primary 1D
cards/documents in Item A or two (2) secondary ID
cards/documents in item B both with signature and at
least one (1) with photo,
2. Filed by Member's Representative
Present the following
2.1 Original of any one (1) of the Authorized
Representative’s primary ID cards/documents in
Item__A or two (2) secondary 1D
cardsidocuments in Item B both with signature
and at least one with photo; and
2.2 Original of any one (1) of the Member's primary
ID -cards/documents in Item _A or two (2)
secondary ID cardsidocuments in Item B both
with signature and at least one (1) with photo,