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CLD-9A Sickness Benefit Application Form (for Unemployed/Self-Employed/Voluntary)
SSS application form for sickness benefit
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: CLAIM NO.
Republic of the Philippines
SOCIAL SECURITY SYSTEM
DATE FILED
SICKNESS BENEFIT APPLICATION FORM
(FOR UNEMPLOYED/SELF-EMPLOYED/VOLUNTARY MEMBERS)
SSS FORM CLD-9A
SS NUMBER
CLAIMANT(FIRST, MIDDLE INITIAL, LAST)
DATE OF BIRTH DATE WHEN EMPLOYEE
BECAME SS MEMBER
ADDRESS (GIVE FULL ADDRESS)
DATE WHEN CLAIMANT
NOTIFIED SSS
CONFINEMENT
A. STARTED ON (FROM) B. ENDED UP TO (LAST DAY) C. PLACE CONFINED
HOSPITAL
D. NO. OF DAYS
HOME
WERE YOU EMPLOYED AT ANY TIME DURING THE PERIOD OF SICKNESS FOR WHICH BENEFIT IS BEING CLAIMED? (PLEASE CHECK PROPER BOX.)
(FILL UP SUCCEEDING DATA)
(FILL UP SUCCEEDING DATA)
YES
NO
EMPLOYER
LAST EMPLOYER
ADDRESS
ADDRESS
PERIOD OF EMPLOYMENT (EXACT DATES)
EMPLOYER I.D. NO. EXACT DATE OF SEPARATION TOTAL MONTHLY SALARY CREDITS
CERTIFICATION OF SEPARATION
THIS IS TO CERTIFY THAT THE CLAIMANT HAS BEEN SEPARATED FROM COMPANY EFFECTIVE ___________________ 19___.
PRINTED NAME AND SIGNATURE OF COMPANY REPRESENTATIVE
OFFICIAL DESIGNATION
I HEREBY CERTIFY THAT THE ABOVE INFORMATION ARE CORRECT TO THE BEST OF MY KNOWLEDGE.
BIR TAX ACCOUNT NUMBER
SIGNATURE OF CLAIMANT
PREVIOUS EMPLOYERS (IF ANY)
INCLUSIVE PERIODS OF EMPLOYMENT
ADDRESS
(TO BE FILLED IN BY CLAIMANT)
ACKNOWLEDGEMENT RECEIPT
FROM: SOCIAL SECURITY SYSTEM, QUEZON CITY
TO: POSTMASTER
SICKNESS CLAIM INDEX CARD
NAME OF CLAIMANT
SS NO.
PLEASE DELIVER THIS RECEIPT TO
CLAIMANT
ADDRESS
ADDRESS
CONFINEMENT PERIOD(EXACT DATES)
FROM
CLAIM NO.
RECEIVED BY
Internet Edition (7/2000)
DATE FILED
DO NOT FILL
TO
FOR SSS USE
CLAIM NO.
RECEIVED BY
DATE FILED
INSTRUCTIONS
1.
Submit only one (1) copy. Avoid erasures or alterations.
2.
If personally filed, submit this SSS form directly to the SSS Medical Evaluation Department.
3.
If confined member is a married woman, print reported name at coverage.
4.
Fill in the dates required in the format Month-- Day-- Year.
5.
Certification of separation is not necessary when the company is on strike, dissolved or closed, or
when there is a case pending before a court regarding separation of the claimant. The following table
shows the document required for any of these cases:
CONDITION
DOCUMENT REQUIRED
a.
Certification from CIR or Department of Labor and
Employment
b.
Company dissolved or closed
Affidavit by the claimant to this effect
c.
6.
Company on strike
Pending case before a court
Certification from the court
The 12-month period where to select the six highest Salary Credits:
Example:
CONFINEMENT
January to March 1998
April to June 1998
July to September 1998
October to December 1998
PERIOD
October 1996 to September 1997
January 1997 to December 1997
April 1997 to March 1998
July 1997 to June 1998
