APPLICATION FOR DISABILITY RETIREMENT (RA 660/RA 8291)/LIFE INSURANCE BENEFIT

Form No. 02202024-ADR-REV 01

INSTRUCTIONS: Ensure that the application form is properly filled out and submit duly accomplished application form to the nearest
GSIS/Handling Office. Do not leave any blank items and indicate check marks ( ) on the provided boxes, when necessary.
WARNING: Direct or indirect commission of fraud, collusion, falsification, misrepresentation of facts, or any other kind of anomaly in
the accomplishment of this form, or in obtaining any benefit under this application shall be subject to administrative, civil and/or criminal
action. THIS FORM IS NOT FOR SALE.
Date:
I hereby apply for a retirement/separation benefit with the GSIS and declare to the best of my knowledge the following:
Last Name First Name Middle Name GSIS Business Partner (BP) No.

Complete Mailing Address

Date of Birth (mm/dd/yyyy) Place of Birth

Contact No. (Landline) Cellphone No. E-mail address:
Civil Status Married Single Separated Widow/Widower Gender
If married, Name of Spouse: (Last Name, First Name, Middle Name) Date of marriage:

I choose to avail of retirement benefits due to disability, effective ___________________________________________.

I affix my signature beside my chosen option. (Please refer to Terms and Conditions of each retirement mode on subsequent pages)
RETIREMENT LAW RETIREMENT OPTIONS SIGNATURE
RA 660 Below age 60, monthly annuity payable annually for 5 years
Aged 60 to below 63, 3-year lump sum, 2 years balance payable on the 63rd
Birthday; monthly annuity after the 5-year guaranteed period
Aged 63 and above, 5-year lump sum, monthly annuity after the 5-year guaranteed
period

RA 8291 Option 1: 60 months x BMP, and BMP after 5 years

Option 2: 18 months x BMP and BMP to start on date of retirement
DECLARATION OF I undertake to submit my Declaration of Pendency/Non-Pendency of Case, duly subscribed and sworn to before
PENDENCY/ a Notary Public or Administering Officer of my agency-employer, as a condition for the release of my retirement
NON-PENDENCY OF benefit and in compliance with Section II of CSC Resolution No. 1302242 dated 01 October 2013.
CASE

LIFE INSURANCE BENEFIT

Type of Life Insurance: Compulsory Optional Policy No. (if claiming for Optional Policy): ___________

NAME OF CLAIMANT IF MEMBER IS DECEASED:

Last Name First Name Middle Name GSIS Business Partner (BP) No.

Complete Mailing Address

Date of Birth (mm/dd/yyyy) Relationship to Deceased Member: Contact No./Cellphone No.

Type of benefit applied for:

Maturity Benefits
Cash Surrender Value/Termination Value, in view of my
retirement effective _____________________________
resignation/separation from the government service on _____________________________
state other reason/s __________________________________________________________
Death Benefits: Date of Death: _____________________________
Accidental Death Benefit (ADB) (applicable for CM(LEP)/Optional policies)
DATA PRIVACY CONSENT
I hereby confirm my understanding of the Privacy Policy of the GSIS pursuant to the requirements of R.A. 10173, otherwise known as
the DPA, its Implementing Rules and Regulations and other issuances of the National Privacy Commission and consent to the manner
of and safety measures to be observed in the collection, use, access, disclosure, processing and disposal of my personal and sensitive
personal data by the GSIS.

Witnesses to thumbmark:

1.

2.
Signature of Applicant over printed name Right Thumbmark
(If unable to affix signature)

Claim proceeds shall be electronically credited to your eCard/UMID account and may be withdrawn from your nearest bank or ATM.
If you have no eCard/UMID, the proceeds will be paid thru check

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 TO BE FILLED OUT BY HEAD OF AGENCY OR HIS AUTHORIZED ENDORSING OFFICER
1st Endorsement
Respectfully forwarded to GSIS this application for retirement/separation benefit with our recommendation for approval.
It is hereby certified that the applicant: (Place a check [ √ ] mark on the pertinent box only)
1. has rendered/will render his Last Day of Actual Service (LDAS) on _________________.
2. has not incurred Leave of Absence Without Pay (LWOP).
3. has incurred Leave of Absence Without Pay (LWOP) from (mm/dd/yyyy) ____________ to (mm/dd/yyyy)
____________. (Please attach separate sheet if necessary)
4. has no pending administrative/criminal case.
5. has pending administrative/criminal case at ___________________________________.
6. has a decided administrative case with __________________. (Please attach certified copy of decision)
7. has a decided criminal case with __________________. (Please attach certified copy of decision)
8. is applying for Refund of Premiums under RA1616 and the application for gratuity benefit has been approved by this
Office.

Office Name

Signature over Printed Name of the Head of

Agency or his Authorized Endorsing Officer
Office Address

Date:

DOCUMENTARY REQUIREMENTS
1. Application Form
2. Proofs of Disability - Parts I, II, and III
3. Service Record with Certification (indicating specific dates and time of sick leave with or without pay)
4. Declaration of Pendency/Non-Pendency of Case (DPNPC) Form (date administered/ notarized should be on or after
receipt of notification from GSIS)
5. Other documents that may be required by the GSIS’ Medical Evaluator

TERMS AND CONDITIONS

Disability Benefits

Disability refers to any loss or impairment of the normal functions of the physical and/or mental faculties of a member, which permanently or temporarily
prevents him to continue with his work or engage in any other gainful occupation resulting in the loss of income. The corresponding disability benefits for
each kind of disability shall be granted to a member based on the duration of incapacity to work and actual loss of income. There are three (3) kinds of
disability which shall be determined by the GSIS based on established medical standards: a) Permanent Total Disability, b) Permanent Partial Disability,
and c) Temporary Total Disability.
I. Policies Governing Disability Benefits:

1. Permanent Total Disability (PTD) – disability due to injury or disease causing complete, irreversible and permanent incapacity that will permanently
disable a member to work or to engage in any gainful occupation resulting to loss of income. The following disabilities shall be deemed total and
permanent:

a. complete loss of sight for both eyes; d. brain injury resulting in incurable imbecility or insanity such other
b. loss of two limbs at or above the ankle or wrists; cases as may be determined and approved by the GSIS
c. permanent complete paralysis of two limbs

2. Permanent Partial Disability (PPD) – arises due to the complete and permanent loss of the use of any of the following resulting to the disability to
work for a limited period of time:

 any finger  any toe  one or both ears hearing

 one arm  one hand  of one or both ears
 one foot  one leg  sight of one eye
 such other cases as may be determined
and approved by the GSIS

3. Temporary Total Disability (TTD) – accrues or arises when the impaired physical and/or mental faculties can be rehabilitated and/or restored to
their normal functions, but such disability shall result in temporary incapacity to work or to engage in any gainful occupation.

4. Any disability or injury as a result of, or due to grave misconduct, participation in riots, gross and inexcusable negligence, under the influence of
drugs or alcohol or willful intention to injure or kill himself or another, shall not be compensable.

5. The actual loss of income shall refer to the number of days when a member went on leave of absence without pay (LWOP) reckoned immediately
from the date of commencement of disability and for the duration of entitlement thereto, based on medical evaluation. Any LWOP incurred after
the duration of entitlement to the benefit shall not be compensable.

6. If the member has two or more different contingencies during the same period of benefit entitlement, he shall be compensated only once for the
overlapping periods.

7. Any applicable disability benefit shall be suspended when he/she:

a. is re-employed; or
b. recovers from his/her disability as determined by the GSIS, whose decision shall be final and binding; or
c. fails to present himself for medical examination when required by GSIS or is receiving any other pension either from GSIS or another local or
foreign institution or organization.

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II. Computation of Benefit:

PTD A member who becomes permanently and totally disabled shall be entitled to the monthly income benefits for life equivalent to the
basic monthly pension (BMP) effective from the date of disability.
PPD The period of entitlement to PPD benefit shall be determined after due medical evaluation; but such period of entitlement to the benefit
shall not exceed 12 months for the same contingency. Only the leave of absence/s without pay incurred during the period of
entitlement, duly certified by the authorized officer of the agency where he is employed, shall be compensable. The amount of PPD
benefit shall be computed by dividing the BMP by 30 days and multiplying the quotient by the number of compensable calendar days
of leave of absence without pay (LWOP).
TTD The period of entitlement to TTD benefit shall be determined after due medical evaluation and proof of actual loss of work resulting in
loss of income by way of the incurred actual number of days of leave of absence/s without pay duly certified by the authorized officer
of the agency where he is employed; but such period of entitlement to the benefit shall not exceed 120 days in one calendar year.
However, if the disability requires more extensive treatment that lasts beyond 120 days, the payment of the TTD may be extended by
the GSIS but not to exceed a total of 240 days. Only the leave of absence/s without pay incurred during the period of entitlement shall
be compensable. Entitlement, however, shall start from the fourth day of the disability. The amount of TTD benefit shall be computed
by multiplying 75% of the daily salary of the member by the number of days of disability based on the medical evaluation but not to
exceed 240 days for the same contingency. However, the computed daily salary shall not be less than seventy pesos (P70.00) but
not to exceed P340.00 per day.

For the purpose of computing the corresponding benefit of inactive members for each kind of disability, the BMP, with respect to PTD and PPD, and daily
salary, with respect to TTD, shall be computed as of the time of separation from GSIS.
III. Conditions for Entitlement:

PTD A member who becomes permanently and totally disabled shall be entitled to the PTD benefits when:
a. he/she is in the service at the time of disability; or
b. if separated from the service, he has paid at least thirty-six (36) months contributions within the five-year (5) period immediately
preceding his/her disability; or has paid a total of at least one hundred eighty (180) months contributions prior to his/her
disability;

Provided, however, that the following conditions shall be met:

a. he/she is gainfully employed prior to the commencement of disability resulting in loss of income as evidenced by any
incontrovertible proof thereof;
b. he/she is not a registered member of any social insurance institution; and
c. he/she is not receiving any other pension either from GSIS or another local or foreign institution or organization
• In addition to the monthly income benefits for life, a cash payment equivalent to eighteen (18) times his/her basic monthly
pension (BMP), shall be paid to a member who was in the service at the time of his/her permanent total disability and who
has paid a total of one hundred eighty (180) monthly contributions.
• A separated member who has at least three (3) years of service and becomes permanently and totally disabled but has
not paid a total of at least one hundred eighty (180) monthly contributions prior to his/her disability shall be entitled only
to cash payment equivalent to one hundred percent (100%) of his/her average monthly compensation for each year of
service with paid contributions but not less than twelve thousand pesos (P12,000.00).
PPD A member whose disability is partial shall be entitled to the PPD benefit when:
a. he/she is in the service at the time of disability; or
b. if separated from the service, he has paid at least thirty-six (36) months contributions within the five-
year (5) period immediately preceding his/her disability; or has paid a total of at least one hundred eighty
(180) months contributions prior to his/her disability; Provided, however, that the following conditions
shall be met:
• he/she is gainfully employed prior to the commencement of disability resulting in loss of income as evidenced by any
incontrovertible proof thereof;
• he/she is not a registered member of any social insurance institution; and
• he/she is not receiving any other pension either from GSIS or another local or foreign institution or organization
TTD A member shall be entitled to the TTD benefit when:
a. he/she is in the service at the time of disability; or
b. if separated from the service, he has paid at least thirty-six (36) months contributions within the five-year (5) period
immediately preceding his/her disability; or has paid a total of at least one hundred eighty (180) months contributions prior to
his/her disability; Provided, however, that the following conditions shall be met:
• he/she is gainfully employed prior to the commencement of disability resulting in loss of income as evidenced by any
incontrovertible proof thereof;
• he/she is not a registered member of any social insurance institution; and
• he/she is not receiving any other pension either from GSIS or another local or foreign institution or organization.

The payment of TTD benefit may be extended by the GSIS up to a maximum of two hundred forty (240) days, subject to medical
evaluation.

IV. Notice and Filing of Claims and Other Documents Required. A written notice of sickness or injury shall be given by a member or anybody in his/her
behalf within one (1) month from the date of the occurrence of the contingency. (If the member is in the service, the notice shall be given to the GSIS
thru his agency; if separated from the service, the member shall notify the GSIS directly.)

The notice must contain the following information: a) Name and address of the member; b) His/Her agency if in the government or employer if in the
private sector; c) Date and nature of sickness or injury; d) Place of confinement; and e) Any other pertinent information that may be required by the
GSIS.

V. Periodic Medical Report – The disabled member, except those with permanent partial disability, shall submit annual medical reports on his/her
impairment, duly certified by his/her attending physician, and/or submit himself/herself to annual medical and physical examination. If he/she fails to
comply with this requirement, the payment of his/her benefit shall be suspended and shall be resumed only upon his/her compliance thereto provided
that, he/she is found still entitled to the benefits. The benefit corresponding to the period of suspension shall also be paid.

VI. Forfeiture of Disability Benefits. - All the foregoing provisions notwithstanding, any member who is enjoying disability benefits shall automatically
forfeit his/her right to the continued enjoyment thereof if he/she refuses or deliberately fails to:

a. have himself/herself medically treated by a physician when required by the GSIS; or

b. take the prescribed medications; or
c. have himself/herself confined in a hospital without justifiable reason, when such confinement is required by the GSIS; or
d. avail himself/herself of such rehabilitation facilities as may be duly recommended by the GSIS and made available for him/her; or
e. observe such precautionary and /or preventive measures as prescribed by a physician or expressly required of him/her to prevent the
aggravation or continuance of his/her disability.

However, upon compliance with the requirements, his/her benefits shall be resumed if he/she is still qualified.

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