Republic of the Philippines Department of Education REGION III-CENTRAL LUZON REGIONAL MEMORANDUM, No. __, 8. 2021 APPLICATION FOR COVID-19 CLAIMS. To: | SCHOOLS DIVISION SUPERINTENDENTS ALL CONCERNED 1. This has reference to the compensation benefits of all employees in the government with employce-employer relationship who are mandatory members of Government Service Insurance System (GSIS) due to sickness, accident or death while in the actual performance of duties and functions. 2. This benefit is funded by the Employees’ Compensation Commission under the Employees’ Compensation Program in coordination with the GSIS. 3. It is advised that said claims be filed at the nearest GSIS Branch in your area with the following requirements: Duly accomplished Application Form (see attached) Job Description Clinical Abstract Approved Leave of Absence Certification from the employer that the employee has been on duty when eRoge tested positive or the COVID-19 {. Proof of increased risk why nature of job increased the risk of having COVID-19 g. RT-PCR Result 4, For information and wide dissemination. MAY LAR, PhD, CESO III ional Director AOl:pert & 5 ‘Address: Matalino St. D.M. Governmeat Center, Maimpis, City of San Fernando (P) ‘Telephone Number: (045) 598-8580 to 89; Email Address: region3@deped.gov.ph Tit (GOVERNMENT SERVICE INSURANCE SYSTEM EMPLOYEES COMPENSATION DEPARTMENT San Fernando, Pampanga Date Accomplished: Receive by: Date: REPORT OF INJURY / SICKNESS / DEATH ‘The Manager GSIS Employees Compensation Department San Fernando, Pampanga Sir: Notice hereby given that the employees named below ( ) was injured ( } contracted sickness ( ) died on Hereunder are the partner data: Name: Address ‘Age: Sex Civil Status: () Single (J Married ( ) Widowler Position/Occupation: GSIS Policy No. Salary: Basic: Allowances: 1. INJURY OR SICKNESS Nature of injury/sickness Data of injury/sickness Time of injury/sickness Place where accident occur epee eenueisanereeseeeeee ° ee Describe Tully how accident happened and what the employee was doing when injured. oO Oo oO ‘. Nameof Hospital g. _ Attending Physician NL DEATH Date of death 9 a ee ect Coot gg oeanaeomnnenneaeeeennseeraeeaeeE c Cause of death tn case of death submit death certificate certified by the Civil Registr Very truly yours Head of Office (Employer) Designation