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03102014-ADR Application for Disability Retirement
GSIS application for disability retirement under RA 660/RA 8291
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: FORM N O . 03102014-ADR
APPLICATION FOR DISABILITY RETIREMENT (RA 660/RA 8291)
(Please Read Terms and Conditions and Documentary Requirement at the back)
INSTRUCTIONS: Ensure that the application form is properly filled out and submit duly accomplished application form
to the nearest GSIS/Handling Office.
WARNING: Direct or indirect commission of fraud, collusion, falsification, misrepresentation of facts, or any other kind
of anomaly in the accomplishment of this form, or in obtaining any benefit under this application shall be subject to
administrative, civil and/or criminal action.
Date: ______________________________
I hereby apply for a retirement/separation benefit with the GSIS and declare to the best of my knowledge the
following:
Last Name
First Name
Middle Name
GSIS Business Partner (BP) No.
Complete Mailing Address
Date of Birth (mm/dd/yyyy)
Contact No. (Landline)
Place of Birth
Cellphone No.
Civil Status
Married
E-mail address:
Gender:
Single
Separated
Widow/Widower
If married, Name of Spouse: (Last Name, First Name, Middle Name)
Female
Male
Date of Marriage
I choose to avail of retirement benefits due to disability, effective ____________________________________________.
I affix my signature beside my chosen option. (Please refer to Terms and Conditions of each retirement mode on
subsequent pages)
RETIREMENT LAW
RETIREMENT OPTIONS
SIGNATURE
Below age 60, monthly annuity payable annually for 5 years
RA 660
Aged 60 to below 63, 3-year lump sum, 2 years balance payable on the
63rd birthday; monthly annuity after the 5-year guaranteed period
Aged 63 and above, 5-year lump sum, monthly annuity after the 5-year
guaranteed period
Option 1: 60 months x BMP, and BMP after 5 years
RA 8291
Option 2: 18 months x BMP and BMP to start on date of retirement
DECLARATION OF
PENDENCY/ NONPENDENCY OF CASE
I undertake to submit my Declaration of Pendency/Non-Pendency of Case, duly subscribed
and sworn to before a Notary Public or Administering Officer of my agency-employer, as a
condition for the release of my retirement benefit and in compliance with Section II of CSC
Resolution No. 1302242 dated 01 October 2013.
Printed Name and Signature of
Witnesses to Thumb mark:
1. _______________________________
_________________________________________
Signature of Applicant over Printed Name
-
Thumb mark
(if unable to affix signature)
continue at the back page -
2. _______________________________
Claim proceeds shall be electronically credited to your eCard/UMID account and may be withdrawn from your nearest
bank or ATM. If you have no eCard/UMID, the proceeds will be paid thru check.
TO BE FILLED OUT BY HEAD OF AGENCY OR HIS AUTHORIZED ENDORSING OFFICER
1st Endorsement
Respectfully forwarded to GSIS this application for retirement/separation benefit with our recommendation for
approval.
It is hereby certified that the applicant: ( Place a check [√] mark on the pertinent box only)
1.
has rendered/will render his Last Day of Actual Service (LDAS) on _____________________________________________.
2.
has not incurred Leave of Absence Without Pay (LWOP).
3.
has incurred Leave of Absence Without Pay (LWOP) from (mm/dd/yyyy) _____________________________________ to
(mm/dd/yyyy) _________________________________________. (Please attach separate sheet if necessary)
4.
has no pending administrative/criminal case.
5.
has pending administrative/criminal case at ______________________________________________________________
6.
has a decided administrative case with ________________________________. (Please attach certified copy of Decision)
7.
has a decided criminal case with _____________________________________. (Please attach certified copy of Decisi
8.
is applying for Refund of Premiums under RA1616 and the application for gratuity benefit has been approved by this
Office.
Office Name
____________________________________________
Signature over Printed Name of the Head of
Agency or his Authorized Endorsing Officer
Date: _____________________________________
_________________________________________________
Office Address
_________________________________________________
Application Received By:
Date Received:
TMS Reference No.:
DOCUMENTARY REQUIREMENTS
1. Application Form
2. Proofs of Disability Parts I, II, and III
3. Declaration of Pendency/Non-Pendency of Case
4. Other documents that may be required by the GSIS’ Medical Evaluator
TERMS AND CONDITIONS
Disability Benefits
Disability refers to any loss or impairment of the normal functions of the physical and/or mental faculties of a member, which
permanently or temporarily prevents him to continue with his work or engage in any other gainful occupation resulting in the loss of
income. The corresponding disability benefits for each kind of disability shall be granted to a member based on the duration of
incapacity to work and actual loss of income. There are three (3) kinds of disability which shall be determined by the GSIS based on
established medical standards: a) Permanent Total Disability, b) Permanent Partial Disability, and c) Temporary Total Disability.
I.
Policies Governing Disability Benefits:
1. Permanent Total Disability (PTD) – disability due to injury or disease causing complete, irreversible and permanent incapacity
that will permanently disable a member to work or to engage in any gainful occupation resulting to loss of income. The
following disabilities shall be deemed total and permanent:
a. complete loss of sight for both eyes;
b. loss of two limbs at or above the ankle or wrists;
c. permanent complete paralysis of two limbs
d.brain injury resulting in incurable imbecility or insanity
e. such other cases as may be determined and approved by the GSIS
2. Permanent Partial Disability (PPD) – arises due to the complete and permanent loss of the use of any of the following resulting
to the disability to work for a limited period of time:
any finger
one arm
one foot
any toe
one hand
one leg
one or both ears
hearing of one or both ears
sight of one eye
such other cases as may be determined and approved by the GSIS
3. Temporary Total Disability (TTD) – accrues or arises when the impaired physical and/or mental faculties can be rehabilitated
and/or restored to their normal functions, but such disability shall result in temporary incapacity to work or to engage in any
gainful occupation.
4. Any disability or injury as a result of, or due to grave misconduct, participation in riots, gross and inexcusable negligence, under
the influence of drugs or alcohol or willful intention to injure or kill himself or another, shall not be compensable.
5. The actual loss of income shall refer to the number of days when a member went on leave of absence without pay (LWOP)
reckoned immediately from the date of commencement of disability and for the duration of entitlement thereto, based on
medical evaluation. Any LWOP incurred after the duration of entitlement to the benefit shall not be compensable.
6. If the member has two or more different contingencies during the same period of benefit entitlement, he shall be
compensated only once for the overlapping periods.
7. Any applicable disability benefit shall be suspended when he/she:
a.
b.
c.
II.
is re-employed; or
recovers from his/her disability as determined by the GSIS, whose decision shall be final and binding; or
fails to present himself for medical examination when required by GSIS or is receiving any other pension either from
GSIS or another local or foreign institution or organization.
Computation of Benefit:
PTD
PPD
TTD
A member who becomes permanently and totally disabled shall be entitled to the monthly income benefits for life
equivalent to the basic monthly pension (BMP) effective from the date of disability.
The period of entitlement to PPD benefit shall be determined after due medical evaluation; but such period of
entitlement to the benefit shall not exceed 12 months for the same contingency. Only the leave of absence/s without pay
incurred during the period of entitlement, duly certified by the authorized officer of the agency where he is employed,
shall be compensable. The amount of PPD benefit shall be computed by dividing the BMP by 30 days and multiplying the
quotient by the number of compensable calendar days of leave of absence without pay (LWOP).
The period of entitlement to TTD benefit shall be determined after due medical evaluation and proof of actual loss of
work resulting in loss of income by way of the incurred actual number of days of leave of absence/s without pay duly
certified by the authorized officer of the agency where he is employed; but such period of entitlement to the benefit shall
not exceed 120 days in one calendar year. However, if the disability requires more extensive treatment that lasts beyond
120 days, the payment of the TTD may be extended by the GSIS but not to exceed a total of 240 days. Only the leave of
absence/s without pay incurred during the period of entitlement shall be compensable. Entitlement, however, shall start
from the fourth day of the disability. The amount of TTD benefit shall be computed by multiplying 75% of the daily salary
of the member by the number of days of disability based on the medical evaluation but not to exceed 240 days for the
same contingency. However, the computed daily salary shall not be less than seventy pesos (P70.00) but not to exceed
P340.00 per day.
For the purpose of computing the corresponding benefit of inactive members for each kind of disability, the BMP, with respect to
PTD and PPD, and daily salary, with respect to TTD, shall be computed as of the time of separation from GSIS.
III.
Conditions for Entitlement:
PTD
PPD
TTD
IV.
A member who becomes permanently and totally disabled shall be entitled to the PTD benefits when:
a. he/she is in the service at the time of disability; or
b. if separated from the service, he has paid at least thirty six (36) months contributions within the five year (5) period
immediately preceding his/her disability; or has paid a total of at least one hundred eighty (180) months
contributions prior to his/her disability;
Provided, however, that the following conditions shall be met:
a. he/she is gainfully employed prior to the commencement of disability resulting in loss of income as evidenced by
any incontrovertible proof thereof;
b. h/she is not a registered member of any social insurance institution; and
c. he/she is not receiving any other pension either from GSIS or another local or foreign institution or organization
In addition to the monthly income benefits for life, a cash payment equivalent to eighteen (18) times his/her
basic monthly pension (BMP), shall be paid to a member who was in the service at the time of his/her permanent
total disability and who has paid a total of one hundred eighty (180) monthly contributions.
A separated member who has at least three (3) years of service and becomes permanently and totally disabled
but has not paid a total of at least one hundred eighty (180) monthly contributions prior to his/her disability shall
be entitled only to cash payment equivalent to one hundred percent (100%) of his/her average monthly
compensation for each year of service with paid contributions but not less than twelve thousand pesos
(P12,000.00).
A member whose disability is partial shall be entitled to the PPD benefit when:
a. he/she is in the service at the time of disability; or
b. if separated from the service, he has paid at least thirty six (36) months contributions within the five year (5)
period immediately preceding his/her disability; or has paid a total of at least one hundred eighty (180) months
contributions prior to his/her disability; Provided, however, that the following conditions shall be met:
he/she is gainfully employed prior to the commencement of disability resulting in loss of income as evidenced by
any incontrovertible proof thereof;
he/she is not a registered member of any social insurance institution; and
he/she is not receiving any other pension either from GSIS or another local or foreign institution or organization
A member shall be entitled to the TTD benefit when:
a. he/she is in the service at the time of disability; or
b. if separated from the service, he has paid at least thirty six (36) months contributions within the five year (5) period
immediately preceding his/her disability; or has paid a total of at least one hundred eighty (180) months contributions
prior to his/her disability; Provided, however, that the following conditions shall be met:
he/she is gainfully employed prior to the commencement of disability resulting in loss of income as evidenced by
any incontrovertible proof thereof;
he/she is not a registered member of any social insurance institution; and
he/she is not receiving any other pension either from GSIS or another local or foreign institution or organization
The payment of TTD benefit may be extended by the GSIS up to a maximum of two hundred forty (240) days, subject to
medical evaluation.
Notice and Filing of Claims and Other Documents Required. - A written notice of sickness or injury shall be given by a
member or anybody in his/her behalf within one (1) month from the date of the occurrence of the contingency. (If the
member is in the service, the notice shall be given to the GSIS thru his agency; if separated from the service, the member
shall notify the GSIS directly.)
The notice must contain the following information: a) Name and address of the member; b) His/Her agency if in the
government or employer if in the private sector; c) Date and nature of sickness or injury; d) Place of confinement; and e)
Any other pertinent information that may be required by the GSIS.
V.
Periodic Medical Report – The disabled member, except those with permanent partial disability, shall submit annual
medical reports on his/her impairment, duly certified by his/her attending physician, and/or submit himself/herself to
annual medical and physical examination. If he/she fails to comply with this requirement, the payment of his/her benefit
shall be suspended and shall be resumed only upon his/her compliance thereto provided that, he/she is found still entitled
to the benefits. The benefit corresponding to the period of suspension shall also be paid.
VI.
Forfeiture of Disability Benefits. - All the foregoing provisions notwithstanding, any member who is enjoying disability
benefits shall automatically forfeit his/her right to the continued enjoyment thereof if he/she refuses or deliberately fails
to:
a.
b.
c.
d.
e.
have himself/herself medically treated by a physician when required by the GSIS; or
take the prescribed medications ; or
have himself/herself confined in a hospital without justifiable reason, when such confinement is required by the
GSIS; or
avail himself/herself of such rehabilitation facilities as may be duly recommended by the GSIS and made available
for him/her; or
observe such precautionary and /or preventive measures as prescribed by a physician or expressly required of
him/her to prevent the aggravation or continuance of his/her disability.
However, upon compliance with the requirements, his/her benefits shall be resumed if he/she is still qualified.
