Did you know that the Department of Defense (DoD) has a form specifically for doctors to report instances of medical malpractice? That's right, the DD Form 2, otherwise known as the Report of Medical Malpractice. This form is used to document any and all malpractices by military or contracted medical personnel. It's important to understand how this form works and what it covers so that you can protect yourself and your loved ones should something happen while receiving treatment from a DoD doctor or contractor. Let's take a closer look at the DD Form 2.
| Question | Answer |
|---|---|
| Form Name | Ddr 2 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | guarantors form sss, sss guarantor's form bpn 107, guarantors form sss meaning, disability claim application sss form ddr1 |
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Republic of the Philippines |
SOCIAL SECURITY SYSTEM |
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DEATH, DISABILITY, RETIREMENT AND EARLY WITHDRAWAL CLAIM |
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(REV. |
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(Please read instructions at the back, Print all information in capital letters & use blank ink only) |
MEMBER'S SS NUMBER (must be 10 digits)
MEMBER'S NAME (SURNAME) |
(GIVEN NAME) |
(MIDDLE NAME) |
ADDRESS (NUMBER & STREET) |
(BARANGAY) |
(TOWN/DISTRICT) |
(CITY/PROVINCE) |
POSTAL CODE
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DATE OF BIRTH (MM/DD/YYYY) |
CLAIM TYPE |
BENEFIT OPTION (Check option) |
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DEATH |
LUMPSUM |
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PENSION |
BOTH |
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DISABILITY |
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Indicate the no. of years |
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TELEPHONE NO. |
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LUMPSUM: P |
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RETIREMENT |
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NO. OF YEARS |
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NO. OF YEARS |
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EARLY WITHDRAWAL |
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OF PENSION: |
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DEPENDENT CHILDREN |
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DATE OF BIRTH |
Check Applicable Column |
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ADDRESS |
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(Beginning from the youngest) |
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(MM/DD/YYYY) |
LEGITIMATE |
ILLEGITIMATE |
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NAME OF BANK/BRANCH
BANK ADDRESS
ACCOUNT NUMBER
BRSTN(SSS to fill in this portion)
CLAIMANT'S NAME (SURNAME) |
(GIVEN NAME) |
(MIDDLE NAME) |
DATE OF BIRTH (MM/DD/YYYY)
RELATIONSHIP TO MEMBER
Photo
1 x 1
Signature of Claimant |
Date |
WITNESSES TO FINGERPRINTS (If claimant cannot sign)
1. |
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Signature Over Printed Name |
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Date |
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2. |
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Signature Over Printed Name |
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Date |
RIGHTTHUMBMARK |
RIGHT INDEX |
REMARKS |
NO OTHER |
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CLAIM FILED |
FOR SSS USE ONLY
CLEARED/DATE
RECEIVED/DATE:
Signature Over Printed Name
Signature Over Printed Name
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SOCIAL SECURITY SYSTEM |
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ACKNOWLEDGEMENT RECEIPT |
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PLEASE PRESENT THIS WHEN INQUIRING |
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DEATH, DISABILITY, RETIREMENT, |
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ABOUT THE STATUS OF YOUR APPLICATION. |
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AND EARLY WITHDRAWAL CLAIM |
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VERIFICATION WILL BE ENTERTAINED AFTER |
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_______ DAYS FROM THE DATE OF RECEIPT |
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MEMBER'S SS NUMBER (must be 10 digits) |
MEMBER'S NAME (SURNAME) (GIVEN NAME) |
(MI) |
FOR SSS USE ONLY |
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DATE RECEIVED |
RECEIVED BY |
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GENERAL INSTRUCTIONS
1.Accomplish this form in one (1) copy without erasures or alterations.
2.If claimant cannot sign, affix right thumbmark and right index on the spaces provided and must be identified by two (2) witnesses.
3.If the benefit option selected is pension, submit photocopy together with the original copy of single savings account passbook.
W A R N I N G
ANY PERSON WHO MAKES FALSE STATEMENTS IN THIS APPLICATION OR SUBMITS FALSIFIED DOCUMENTS IN CONNECTION WITH HIS CLAIM SHALL BE LIABLE CRIMINALLY FOR FALSIFICATION OF PUBLIC DOCUMENTS.
CHECKLIST OF REQUIRED DOCUMENTS AND SPECIFIC INSTRUCTIONS
DEATH
Primary Beneficiaries
Death Certificate of member Marriage Certificate Birth/Baptismal Certificates of minors
Medical Certificate of incapacitated child, if any Death Certificate of spouse, if already deceased Application for Representative Payee
Proof of relationship such as record of birth, a statement before a court of record or any authentic writing/document
-Duly registered with Local Civil Registry Office
-Duly registered with Local Civil Registry Office
-Duly registered with Local Civil Registry Office/Parish Church
-To be accomplished by the child's attending physician
-Duly registered with Local Civil Registry Office
-To be accomplished by the guardian of the minor children other than parent
-To be accomplished by a guarantor, if minor children are under a guardian
-To be submitted for illegitimate children
Secondary Beneficiaries
If Claimant is Parent |
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Death Certificate of member |
- Duly registered with Local Civil Registry Office |
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Birth Certificate of deceased member |
- Duly registered with Local Civil Registry Office/Parish Church |
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Marriage Certificate of parents |
- Duly registered with Local Civil Registry Office/Parish Church |
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If Claimant is other than Parents |
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Death Certificate of parents |
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To be submitted if parents are deceased |
Birth Certificate of the deceased brother/sister |
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To be submitted to prove claimant's relationship with the deceased |
Birth Certificate of minor beneficiaries |
- Duly registered with Local Civil Registry Office/Parish Church |
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Medical Certificate
Operating Room Record
Accident Report
Other medical records that may be requested by
the Medical Benefits Section, Diliman Branch
DISABILITY
-To be accomplished by the claimant's attending physician
-To be secured if claimant has been operated on
-To be secured from the employer
RETIREMENT
Birth Certificate of member |
- To be submitted if with discrepancy in the date of birth |