Form Di-1-Pp - Application For Disability Benefits Covered By Act 139 Page 3
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4PART B
EMPLOYER´S REPORT
1. Worker´s name:
2. Social Security No:
3. Employee´s number:
4. Occupation:
5. Weekly Salary $____________
6. Regular weekly schedule
7. Requires license to make its tasks?
YES
NO
month $___________________
__________ hours
9. The worker contribute to:
8. Are you assured voluntarily with the Act Num. 139 of 1968?
Chauffeurs Insurance
Disability Insurance (SINOT)
______%
Yes
No
Workers included__________________
11. Last date physically worked
10. Employer´s contribution to Disability Insurance
12. Effective suspension in
(SINOT) ________%
(month-day-year)
(month-day-year)
13. Reason for unemployment:
14. Date returned to work
(month-Day-Year):
15. Job – related disability: Yes
No
16. Car related disability: Yes
No
Accident report date (month-day-year)____________________________
SIF Case Num (C.F.S.E.)_______________________________________
17. Are the workers covered for the SINOT by authorized a private plan or self-insured approved by the Secretary of Labor?
Yes
NO
In affirmative case, indicate, Plan number_____________________________
Assurance Company__________________________________________
18. Have you made any payment during the worker´s disability?
Yes
No
In affirmative case, indicate:
P
D
ERIOD
ATE OF PAYMENT
K
(
-Day-Year)
IND OF PAYMENT
T
F
Through
month
AMOUNT
OTAL DAYS
ROM
(
(month -Day-Year)
month-Day-Year)
GROSS
Vacations
Sick leave
Maternity leave
Voluntary Pay
Exemption
Payroll
Pension o retirement
Holiday pay Which are?
Others (Specify)
19. If this is a maternity claim under Act 3, indicate the weekly wage or average used for the payment by the Act No. 3 of 1942: $____________________.
If there was no payment, explain:
20. Company´s Name:
Postal Address:
Local Address:
Phone:
Fax:
E-mail:
Unemployment and
FEDERAL account
Disability Insurance
number
-
Account Number
21. QUARTERS WORKED*
YEAR
WAGES
22. In case of AGRICULTURAL WORK, COMPLETE:
Farm´s name and number:
January to March
2
$
April to June
2
$
July to September
2
$
October to December
2
$
*Submit evidence: Copy quarterly lists and cancelled checks.*
CERTIFICATION
I certify that the information I am submitting in this form is correct. I know that the Act 139, in Section 11 (a), imposes severe
penalties---as it fines, jail or both pains, to discretion of Court-by offering deception relative to a claim of disability benefits.
Employer’ name (or authorized representative, in printed)
Position
Employer’s signature (or authorized representative)
Date
(month -day-year)
OFFICIAL USE
Authorized civil employee
Authorized civil employee
THE EMPLOYER HAS PRIVATE PLAN
THE PLAN IS CONTRIBUTORY: SI
NO
YES
NO
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