BB csisexemssessrassen (CHECKLIST-FOR APPLYING FOR EMPLOYEES COMPENSATION / COVID 19 (C2 1. Duty ACCOMPLISHED EC REPORT OF INJURY /SICKNESS /DEATH INCOME BENEFITS CLAIM FOR PAYMENT FORM -DULY SIGNED. HOSPITALIZATION CLAIM FOR PAYMENT, IF ADMITTED, IF NOT PART Il: ATTENDING PHYSICIAN CERTIFICATION 2 2. service Record {23 CERTIFICATION Front THE EMPLOYER THAT THE WORKER HAS BEEN ON DUTY OURING T STATEMENT OF ACTUAL DUTIES (G5. MEDICAL DIAGNOSIS SHOWING THAT THE CLAIMANT WAS DIAGNOSED AS POSITIVE OF T WHILE ON DUTY OURING THE PERIOD OF THE OUTBREAK - RESULT OF RT PCR TEST 6. STATEMENT OF HOSPITAL EXPENSES , ITEMIZED LIST, IF ADMITTED. C3 7. OFFICIAL RECEIPTS OF HOSPITAL PAYMENTS AND MEDICINES PURCHASED. C2 &. CERTIFICATION OF SICK LEAVE AT THE TIME OF THE ILLNESS AND DATE RETURN TO WORJ )_ Ortginal Officlat Recotpte of hospital payment & Offical Racetpts of mete GOVERNMSNY SERVICE INSURANCE SYSTEM MEDICAL UNIT DUMAGUETE CITY ‘StevModar: Yor the expeditious settlemant of your cintmns for alyabliity bonat in the systarn, please submit mad/comply with dia folless2 requicomante rissicad (1) below. () Medien! HISTORY ken during confinement (3 Rettramane Voucher { ) Time Card (Ceruifled True Copy) for the Month of ©) Berries Record cord by mmploye, ingesting aed of acta eovien ‘wink pay: rust be ax updaton wuretce () Caretftestion slggued by tha employer ax to: () Tuchusive dates of lexve of absence with snd svtioutt pay. { ) Date of Return to Work ( } eatarnwne of Actual Duttor (Chee X-ray film with reeult properly iderasfled (Wars, date, name of elute Lndtexted) (C) Prior te employment or prior to contraction of te disenee {3 On the fret dlacovery of the disenre C3 Recent ( ) Proote that occupation fnvolvar the (neraeand riaic of contracting ( ) Hospitalization clabn for payment alyned by: € ) Coreiftention from Emnployar ns i (C3 Hospital Officials Employees? Compensncson (EC) ( ) Attending margeons ‘praraiurn remiteancs to thly offies (9 Auomthostologiee { ) Ceretned eras copy of EC togboak ( ) Howpleal and/or eltnteal records of continemanyconzultatlon puszuant to KC Board Res, #99-12-0785 Cy Mendaed Vint and cost of madieiner () Marriage Contract f) Cartified tras copy of OPERATING ROOM RECORD ( ). Bisth Certifiente of Chlidren ( } Certitied true copy of BIOPSY REPORT 1) Proofs of Surviving Lemd Botrs forms naached) Cy CT Seen Fit and Rent, ©) Copy of total Henpitas 3H ( ) Dincharge Instructions of medicines tohe continued at borne (.) Preseription of stl inedtesnes (> Xeray film with ralt of afectad aren, properly Identified Game, date, Name of clinte Indleste) (E00 Tracings with ranult propscly routed, {AantiMed and xlgned by both applteanc snd FO Kearns: (.) Disebittey Part It forme (copten sacloved) to be necomplisied by « gowarnraont playetcian a Ure : C) it would aot ba too inconvealeat for yous, pleans report to the OSIS Medien! Oni __. . for turcher sxuminsiion; othererina, plaxes tiform ur ff yout cannot do 20: ( ) Dowh Certificate of dacoseed proparty cerritted (rea copter} ( ) Hospital Cluange Bhior (> Dupllente eoples of Parte 1,2, . ( } Hogpitnt Stataminc of Aecoune Deratiaarrernieed () Modieation Racord 6) Tab Bxarew/Misdicnl Proceeds reeiea ims purchased ootalds. «2 ankOnan) DOCUMENTS MUST BE CIRTIVIZD TRON XTROX COPY BY AUTHORIZED PERSON! NOT: Chadians manet be sxhuadSied io Dick Offer wks teres 5 (2) wars fru dante afitoees aw congo we Vary truly yours,Repaibite of the Phillippines GOVERNMENT SERVICE IMURANCE SYSTEM ‘Employees Compensation Dept. ‘Matro Manila Received byy iit eae eer REPORT OF INJURY/SICKNESS DEATH ‘Tee Btanager : ‘Employest? Compensation Departinent (OMS, Manila: ‘Medan Neties is hereby given that the employee mamed below ( ) was injurnd { ) contracted elctasiws ( ) @ad on ——__——" Hlareunder are the pertinent det Bene (Offles Addrece:, _ Addroms __ : - es Ct ata CD finge () Married ©) Witow/er S Cenen tooth {in case of destin, scone dasth cartificata certified by the Local Civil Registrar).r os INCOME BENEFITS CLAIM FOR PAYMENT PART 1 - NMPLOVEN TO PILL IN ALL iTaMe | |SHPLOVER NAME: (Last, Frat. cae) Chl Status: ‘@SIS Poloy No. | |~- s ‘Home Aadreas: Bate FB | ite ren _| Date of Orginal Apporrement: Pace of Bith ‘Actin ition ‘Moritily Salary. [emer {arity tat ueed___ dye of noaptnizaton and ‘Wat pald by my employer an amount of P. hi honve credits. zee ne Tow, a Claimant Right ‘Wines to Thumbriark . - Thumomark Working Hours ‘Specie Pince of Work: i Fave You received or recovared ary amount or damages connecled WUE Gal Wont Hhe Pid parlea? yas Wale GURL ‘ame and accross of auch tid party, {176.40 you band to recover any amount or damages from rd persona? Fea, plouae state narne end eddreee of such ard pereons?, eee eee eee ‘Have you chosen benef uncer other tgws7___ yas, whut beneft and under whet We [ve you received beret thereunder? How much have you received, ART 2- EMPLOYER YO FILL IN ALL ITEM ‘Smployers Regtatered Name: Date end Place of ijurySicinens/Desth | sarees armen Tene War Riper ai pia Sona [Nature or find of Rurysicineen/DeabhtyiDenth, (Ovscribe | CERTIFICATION 1 {uty now weckdent happened end what he employee wee | hereby certify that the contingency has been properly recorded dang et the te of ur, sickness, clawbity or deeth,) Wr sr ebook unde nt No dete Printed Name oF Employer Adborized Reprenertatve é ns forthe days ot [equivalent No. of aye He the Smmplgyee stopped wort? ‘Amount of elary pal forthe dey Wao, hes he retard to work? beence NOTE: Annyone who Toaltes saver requvated by Bie oF &rwelnd form Wey pan sonvcion Be elbjecl ts Whe ‘end uncer tet. A data requir on te form ere receseary for educiceton of te cain, The QSIS wil no wohl te ay ca whore forme ar no propery or cafhpataly wccomplahed.HOSPITALIZATION CLAIM FOR PAYMENT EMPLOYEE'S COMPENSATION ‘Hospital Charges (Ward Services) ‘A Bm Bd & Spociel Charger - —_—--_——-| De ee. "Final Disgrosle Kitached Biaternent of Actial chee ge) B. Surgical ©. Mediciner Cio. Ba ‘TOTAL oo MILE Ee ne “hédrese of Employee CERTICADON ae “Tagloger r=") eartity tna the services clniraed sre duly recorded inthe patlect'« charts, end the Infermation given in thle form including tha attached copy of the pitient's etatarnect ‘Racress ot Binployer "of actu charger ix correct. “ss PART = DOCTOR TO PILLINAALL Temas er “ref Giinaal Fistory ofthe Case (For jon, uae ravarse site here) “"] Code ite. “For parvions rendered alweys wate the nuture of wervioe, mrgioal end dato A Napa al NOTE: Any one who fulsfies esseretel information requested by this or related forra may upoa conriction, be ad Ar Sifclnoccnech under the lew, All deta required onthis form are aeceussry For aijudicetion af the clakn. ‘The GAt2 will ‘ot eddicale any clairn where forme are not jroperly or ccenpletely wecornpliaher,PART Ill—ATTENDING PHYSICIAN'S CERTIFICATION (FILL IN ALL ITEMS) ao Treatment Period (iixact Date) a ‘From To: History of present fiinoss: (Give exact date, If Labor: aoe I possibte | Pertinent PLE. Findings & Laboratory procedures: Sa ie sans coe syirptoms upto the thom of this tory procedur Past history (only those relevant o present, lines): Final Diagnosis: Was the injury or lines directly caused by the eraployees duties? | ee “| Was patent worst tbe Ue of ess? | ‘Meriical valuation Report: (Tor GSIS use only)