Ec Medical Reimbursement Benefit Application Page 4

INSTRUCTIONS

1. Fill in properly all blank spaces.

2. Indicate complete diagnosis including body parts affected:

- head/neck - upper extremities - lower extremities

- eyes

- arms

- legs

- trunk

- head

- foot

- spine

- others

3. If claimant is employee or employer , attach the following:

a. original official receipt with BIR permit number

b. charge slips or statement of account with itemized list or breakdown of

expenses

4. If claimant is hospital , attach charge slips or statement of account with

itemized list or breakdown of expenses.

5. If member is unable to sign , affix thumbprint, with printed name and signature

of witness to thumbprint.

6. If member is deceased , indicate the relationship on the employee portion, with

printed name and signature of witness.

7. Use another sheet if there are more than three payees.

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Parent category: Business