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FOR SSS USE ONLY NAME OF PAYEE TO BE FILLED UP BY EMPLOYER/EMPLOYEE FORM B301 Rev. 02/97 RECEIVED BY CUT HERE ACKNOWLEDGEMENT STUB INSTRUCTIONS 1. Republic of the Philippines SOCIAL SECURITY SYSTEM EC MEDICAL REIMBURSEMENT BENEFIT APPLICATION FORM B301 Rev* 02/97 PLEASE READ INSTRUCTIONS AT THE BACK BEFORE FILLING UP Page 1 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...
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AGE SEX TYPE AND DURATION (State the type of exposure, time, and duration) NUMBER AND STATUS OF RECORDS(for example, records that confirm whether the employee was on the job and was dismissed, on the job for an extended period of time, transferred, laid off, etcetera) PERSONAL RIGHTS OF RECORD I agree if the Department has been notified that they can take this claim against my employer. I believe that I am entitled to have a representative of my own choosing to take care of record keeping and reporting. I understand that if my employer has a responsibility under the Civil Rights Act, it is their responsibility to determine whom to employ or promote in the event of injury, disability, or death resulting from my job. It is my responsibility to report the accident in accordance with the procedures in the employee handbook or the training program. I have been advised by my current employer that they will pay for all medical and hospital expenses if there is an injury, disability or death resulting from my job with them, and I agree to this claim. I agree to the terms and conditions of the settlement. 2. Furthermore, I have been a part of the Filipino Army for 4 years. Furthermore, I work in a chemical company and I own the company. Furthermore, I am involved in the manufacturing of chemical products. Furthermore, I was injured on the night of March 18, 2012, while preparing food for a military operation involving US Armed Forces personnel. Furthermore, I lost consciousness due to my exposure to a toxic, nonlethal substance that I had handled. While unconscious, I experienced vomiting, abdominal pain, diarrhea and loss of consciousness. I regained consciousness and could not breathe due to my lack of air. I went to the nearest hospital, where several nurses attempted resuscitation. Furthermore, I was then taken to another hospital. Furthermore, I was admitted to the Philippine General Hospital, P.G.H., and placed under the effects of General Anesthetics. My condition and condition has worsened due to exposure to the toxic substance that I handled. I have been diagnosed with Toxic Exposure Syndrome by a doctor and had blood tested for my toxic load and found to be well within the limits of acceptable. I am currently on an IV sedation to decrease the effect of the poison on my body. Furthermore, I am currently in stable condition and is in no condition to return to work. Furthermore, I am also suffering from nausea, abdominal pain, diarrhea, and loss of consciousness and am on antibiotics prescribed by a doctor.
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