,~ Republic of the Phlllpplnes

DEPARTMENT OF lABOR AND EMPLOYMENT

SMPLO'l'SSI' COMPSNIATION COMMIIIION
'1111 II. s"' Floors, ECC Bulldll"lg, 355 Sen. GY J. Puyat Avenue, City r;J Makatl

TIILNo. 89M251:899--t252•FuNo. a97-7597°E-mat.~p.ph•w..;i.: ~ :Jlwww.to:.ll(l'I.P,

CASH ASSISTANCE FORM

(for COVIO -19 positive claimants)

Uniformed Personnel D Heatth care worl!:er

Olhen,_ _ _ _ _ _ __
Overseas Seafarer

DATE OF APPLICATION: _ _ _ _ _ _ _ _ __ CONTROL NO.: _ _ _ _ _ __

DEJNLS OF MEMBER I BENEFtclARY

Name of Member. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Date of Birth: _ _ _ _ _ _ _ _ _ _ S.x: Marital Status: _ _ _ _ __
SSS/GSIS I AFPSN Number: _ _ _ _ _ _ _ _ __
AddrnsofMember: _ _ _ _ _ _ _ _~ - ~ - - - - - - - - - - - -
ContactNo.: , - - - - - - - - - - Emall Address: _ _ _ _ _ _ _ _ __
Place of Contingency: _ _ _ _ _ _ _ _ _ _ Date of Contingency: _ _ _ _ __
FOR DEATH

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DOCUMENTS SUBNITJEP·
D Accomplished ECC Cash Aul9tance Applkation Form
Proof of ApproYff EC claim from sss or GSIS
Copy of 2 valld IDs preferably Office/Company ID, SSSIGSIS or other government Issued ID
D lledlcal Abatract/MecNcal CM11ftcat• fofCOVID-19 Hlnesa (to Indicate period of medical attendance of
mneas) or Laboratory (RT.PCR) tHI rnult showing POSITIVE for COVID-19, issued by a DOH
acaudited testing center or Quarantine iHu&d by LOO-Health Otrice/BHERT

Signature of Applicant above Printed Name:

TO BE ACCOMPLISHED BY ECC:
Reconvnendlng the approval of the application for cash assistance in the amount of Php _ _ _ _ _ .

DR. RAYMOND C. BAAi.GA ATTY. JONATHAN T. VILLASOTO

Officer-In-Charge, WCPRD Deputy Executive Director

Approved by,

STELLA ZIPAGAN- BANAWIS

Executive Director