Received by: ________________

Date: ______________________

REPORT OF INJURY / SICKNESS / DEATH

The Manager
GSIS Employees Compensation Department
GSIS, Pasay City, Manila

Sir:
Notice is hereby given that the employee named below was injured
Contracted sickness died on _______________________ hereunder
are the pertinent data:

Name: __________________________________ Office ___________________________________

Address: ________________________________ Address: ________________________________
Age: ___________________ Sex: ____________Civil Status: ____________________________
Position/Occupation: ___________________GSIS Policy No._________________________
Salary: ____________________ Basic: __________________ Allowance: __________________

I. Injury/Sickness
a. Nature of Injury/Sickness : ______________________________________________
b. Date of Injury/Sickness: _________________________________________________
c. Time of injury/Sickness: _________________________________________________
d. Place of accident occurred:_______________________________________________
e. Describe fully how the accident happened and what the employee was doing
when injured: ____________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
f. Name of Hospital: __________________________________________________
g. Attending Physician:________________________________________________

II. Death:
a. Date of Death: _______________________________________
b. Time of death: _______________________________________
c. Cause of Death: ______________________________________

(In case of death, submit death certificate certified by the Local Civil Registrar concerned.)

Date Accomplished: __________________________________

Very truly yours,

___________________________________
(Head of Office-Employer)