Ec Medical Reimbursement Benefit Application

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Republic of the Philippines
EC MEDICAL REIMBURSEMENT BENEFIT APPLICATION
FORM B301
PLEASE READ INSTRUCTIONS AT THE BACK BEFORE FILLING UP
Page 1
(Rev. 02/97)
PART I - EMPLOYER TO FILL IN ALL ITEMS
ACCIDENT/SICKNESS REPORT
NAME OF EMPLOYEE
SS NUMBER
HOME ADDRESS
ZIP CODE
AGE
SEX
M
F
OCCUPATION (State brief description of duties/Specify name of chemicals or substances to which the employee is exposed)
NAME OF EMPLOYER AT THE TIME OF ACCIDENT/SICKNESS
ID NUMBER
ADDRESS
ZIP CODE
PERIOD OF EMPLOYMENT
REGULAR WORKING HOURS
OVERTIME SCHEDULE
AM
AM
AM
AM
From
To
From
PM
To
PM
From
PM
To
PM
DATE OF ACCIDENT/ONSET OF SICKNESS
TIME OF ACCIDENT/SICKNESS
PLACE OF ACCIDENT/SICKNESS
AM
PM
BRIEF DESCRIPTION OF ACCIDENT/SICKNESS (Specify where employee was going at the time of accident or the purpose of the trip and describe
the circumstances of the accident)
PART II - JOINT CERTIFICATION
We hereby certify that all the above information are true and correct.
PRINTED NAME AND SIGNATURE OF
PRINTED NAME AND SIGNATURE OF AUTHORIZED
IMMEDIATE SUPERVISOR
COMPANY REPRESENTATIVE
(If member cannot sign/deceased)
RIGHT THUMBPRINT
(in lieu of signature)
PRINTED NAME AND SIGNATURE OF EMPLOYEE
PRINTED NAME AND SIGNATURE OF WITNESS
NOTE:
ANY MISREPRESENTATION OR FALSIFICATION SHALL BE SUBJECT TO FINE AND IMPRISONMENT UNDER THE
LAW (P.D. 626, ARTICLE 207)
CUT HERE
PLEASE PRESENT THIS RECEIPT WHEN INQUIRING
ACKNOWLEDGEMENT STUB
ABOUT THE STATUS OF YOUR APPLICATION.
SOCIAL SECURITY SYSTEM
TO BE FILLED UP BY EMPLOYER/EMPLOYEE
VERIFICATION WILL BE ENTERTAINED AFTER _____
EC MEDICAL REIMBURSEMENT
FORM B301 (Rev. 02/97)
DAYS FROM THE DATE OF RECEIPT.
NAME OF PAYEE
FOR SSS USE ONLY
DATE RECEIVED
NAME OF EMPLOYEE
SS NUMBER
RECEIVED BY
(SURNAME)
(FIRST NAME)
(MIDDLE NAME)
Internet Edition (7/2000)

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