REPUBLIC OF THE PHILIPPINES

SOCIAL SECURITY SYSTEM

IMPORTANT
ACCIDENT/SICKNESS REPORT IF VEHICULAR ACCIDENT
SSS FORM B-309 (Revised 06/88) eeg ATTACH COPY OF POLICE RE-
PORT
NAME OF EMPLOYEE (Last, First, Middle) SS NUMBER
Ronnie R. Peñaflorida
07 1 8 0 1 6 9 0 4
NAME OF EMPLOYER ADDRESS SS I.D. NUMBER

Hawaiian Philippine Company Brgy. Hawaiian, Silay City

JOB DESCRIPTION OR OCCUPATION

Mill and Boiler Assistant Supervisor

DATE OF ACCIDENT/SICKNESS EXACT TIME PLACE

July 22, 2019 19:50 Hawaiian Philippine Company Court

(Check applicable box)

REGULAR WORKING HOURS OVERTIME
From To From 4pm To 8 pm
DATE LAST REPORTED FOR WORK DATE RETURNED TO WORK
July 22, 2019

BRIEF DESCRIPTION OF ACCIDENT/SICKNESS

At around 7:50 pm, in quarter no.4 of the basketball game between Mill and Boiler and Boiling House Department; where eight
(8) minutes left in the said quarter. Engineer Ronnie Peñaflorida – Mill and Boiler Assistant Supervisor intercept the ball and attempted
to lay-up to the basket, upon the attempt, he suddenly stop and try to balance himself and managed his way out of the court. While
sitting under the post, he was agonizing due to undetermined pain, He felt severe pain and numbness in his left ankle then He was
brought to the hospital for checkup and for proper medication.

SIGNATURE OF IMMEDIATE SUPERVISOR SIGNATURE OF PERSONNEL MANAGER

DATE DATE

(Signature above printed name)

Internet Edition (7/2000)