DISABILITY BENEFITS
INCOME BENEFITS CLAIM FOR PAYMENT
If no, do you intend to recover any amount or damages from 3rd person?If
yes, please state name and address of such 3rd person
EMPLOYER'S REGISTERED NAME DATE AND PLACE OF INJURY/SICKNESS/DEATH
ADDRESS OF EMPLOYEE TIME: Was the employee injured in regular occupation?
Nature or kind of Injuiy / Sickness / Disability / Death CERTIFICATION:
(Describe fully how accident happened and what the I hereby certify that the contingency has been properly recorded in our log book
employee was doing at the time of injury, sickness, disability under Entry No. dated . I further certify that Mr./Ms./Mrs
or death) has not filed any claim under any other benefits for the same
injury, disability or death. Should any claim be filed, that office will be informed
immediately.
SIGNATURE OF AUTHORIZED OFFICIAL CAPACITY
REPRESENTATIVE
Printed Name of Employer's Authorized Representative:
Has injured stopped working? Amount of salaries paid for the days of Equivalent Number of Days
If so, has he returned to work? absence
When?
(If papers submitted are nof sufficient, additional documents may still be required)
Anyone who falsifies essential information requested by this or a related form may, upon conviction be subject to fine and imprisonment
NOTE:
under the law. All data required on this form are necessary for adjudication of the claim. The GSIS will adjudicate any claim where
forms are not properly or completely accomplished.
HOSPITALIZATION CLAIM FOR PAYMENT
EMPLOYEE'S COMPENSATION
PART I -HOSPITAL TO FILL IN ALL ITEMS
Hospital Address PMC NO.
Patient Date Admitted Date Discharged Date of Death
Diagnosis Hospital Charges (Ward Services) BC Actual
A. Room Board & Special Charges
Final Diagnosis days at PhP
B. Surgical
GSIS No. Gender Age
Female C. Medicines
Male
Address of Employee CERTIFICATION
I hereby certify that the seNlc;es clelmed are duly recorded in the patient's
Employer chart and the Information given In this form, Including the attached copy of the
patient statement of actual charges Is correct .
Address of Employer Printed Name of Hospital Authorized Representative
For GSIS Use (Signature Verified by) Official Capacity
Remarks Siganture of Authorized representative Date Signed
PART II -DOCTOR TO FILL IN ALL ITEMS DO NOT FILL
Brief Clinical History of the Case (For clarification, use reverse side hereof)
For services rendered always state the nature of service, surgical CHARGES Code No.
operation performed, if any, and date of each EC Actual
A. Name of Attending Physician/Surgeon Address
Signature
Php Php
PMA No. TIN
Services Rendered
B. Name of Attending Physician/Surgeon Address
Signature
Php Php
PMA No. TIN
Services Rendered
C. Name of Attending Physician/Surgeon Address
Signature
Php Php
PMA No. TIN
Services Rendered
MEDICAL EVALUATION REPORT (For GSIS use only)
Nature or Degree of Sickness/Sickness Noted
Signature
Designation
Date
NOTE: Anyone who falsifies essential information requested by this or a related form may, upon conviction be subject to fine and imprisonment
under the law. All data required on this form are necessary for adjudication of the claim. The GSIS will adjudicate any claim where forms
are not properly or completely accomplished.
Name of Employee Treatment Period (exact date)
From: To:
History of present illness : (Give exact date. If Possible and include Pertinent P.E. Findings and Laboratory procedure:
signs and symptoms up to the time of this report.)
Past history (only those relevant to present illness)
Final Diagnosis:
Was the injury or illness directly caused by the employee's duties?
Degree of disability Was Patient working at the time of illness?
Temporary total
Permanent Total
Permanent Total
Medical Evaluation Report (for GSIS use only)
M.D.
Signature over printed name
PMA No. BIR TIN
Lic. No. Date Issued
