Ec Medical Reimbursement Benefit Application Page 2

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INSTRUCTIONS
1. Fill in all items properly. Please type or print legibly.
2. Attach the following in cases of:
a) vehicular accident
• police report
• specify employee’s destination and purpose of the trip
b) medico-legal incident
• police report
• specify motive of the aggressor in inflicting the injuries
c) work-related illness
• pre-employment physical examination report/ chest x-ray/ ECG reports.
• pertinent clinical records/laboratory and other diagnostic procedures.
Note:
Employee’s Compensation claims should be filed within 3 years from date of
work-related accident or illness.

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