Republic of the Philippines

DOLE Regional/ Field/ Provincial Office: _________________________

DEPARTMENT OF LABOR AND EMPLOYMENT
(Sugar Workers’ Death Benefit Program Evaluation Checklist, Form 1, Ver.01-2022)
Control No/ Series No: ___________________________________________

PART 1. GENERAL INFORMATION

 Spouse 
Parent
(1) Name of (2) Relationship of Claimant to
Claimant: (Last) (First Name) (M.I.) deceased sugar worker  Child 
Others, pls. state:
_____________
(3) Age (of 1): _________________ (4) Contact details:  Mobile/ landline: __________________  Address: ________________________________________
(5) Name of Deceased (6) Age (of 5): (7) Date of Death: (8) Cause of Death:
Sugar Worker: Last) (First Name) (M.I.) ____________ ___________________ ______________________
(6) Name of Sugar Mill (7) Name of Planter Association/
____________________________________ _____________________________________
(where no. 5 last worked) Planter (where no. 5 last worked)
 Mill  Small Planter Cultivator Other, pls. state:_________________________
(8) Type of Worker  Field Worker  MSW/ Sacada
Worker
PART 2. COVERAGE AND CONDITIONS FOR ENTITLEMENT
QUESTIONS RESPONSE REMARKS QUESTIONS RESPONSE REMARKS
YES NO YES NO
(9) Is the (deceased) sugar worker actively (10) Is the death benefit claim being
employed at the time of death? made within three (3) years after the
death of the sugar worker?
a. If YES, did the deceased sugar worker
render at least 3 months or 90 days of (11) If YES to No. 10, the late filing a. ________________________________
continued or aggregate service within of the death benefits is due to b. _______________________________
the current crop year or crop year following reason/s: c. _______________________________
immediately prior to demise?
b. If NO, did the deceased sugar worker (12) Based on responses given to
have rendered at least five (5) years of No.11, area reasons valid or not?
continuous or aggregate service as an a. ________________________________
 If NO, cite explanation
employee of a mill or farm? b. ________________________________
 If YES, did his/ her death occur (13) What documents did he/she
a. ________________________________
within a period of 3 years from present to prove that he/ she is the
b. ________________________________
the date of his/ her last day of authorized representative for the
c. ________________________________
employment? deceased sugar worker?
PART 3. VALIDATION OF SAP DEATH BENEFIT CLAIM AND DOCUMETS SUBMITTED
In addition to counter-verifying with the applicant all the information indicated in the accomplished SAP SWDBP Form, the concerned DOLE Officer
will accomplish/ respond to the following:
DOCUMENT ATTACHED? REMARKS DOCUMENT ATTACHED? REMARKS
YES NO YES NO
If claimant is legitimate spouse: If claimant is the legitimate sibling:
(14) Copy of Death Certificate of the (23) True copy of birth certificate of
deceased sugar worker issued by the deceased sugar worker, certified by the
Local Civil Registrar (LCR) or PSA, or LCR/ PSA
photocopy upon presentation of the (24) True copy of death certificates of
original copy parents of deceased sugar worker,
certified by the LCR/ PSA
(15) Copy of the CBF special payroll (25) True copy of birth certificate of
certified by the employer which will claimant, certified by the LCR/PSA
match or is the same as the file copy of
the concerned DOLE RO If the deceased sugar worker is a small farmer cultivator:
(16) Copy of marriage contract or (26) Are the documentary requirements
marriage certificate duly authenticated mentioned in Item No. 14 and 15 present?
by the LCR or PSA (If NO, state in remarks portion the
missing documents and inform the
If claimant is legitimate child: claimant to provide the same)
(17) Are the documentary requirements (27) Is the documentary requirement
mentioned in Item No. 14 and 15 indicated in Item no. 23 available or
present? (If NO, state in remarks presented by claimant (if applicable)?
portion the missing documents and (28) Is the documentary requirement
inform the claimant to provide the same) indicated in Item no. 24 available or
(18) Copy of his/ her birth certificate presented by claimant (if applicable)?
(indicating that the deceased is one of
(29) Is the documentary requirement
his/her parents), or adoption certificate
indicated in Item no. 25 available or
of claimant certified by the LCR or PSA
presented by the claimant (if applicable)?
If claimant is legitimate ascendant:
(19) Are the documentary requirements (30) Certificate of membership of the
mentioned in Item No. 14 and 15 deceased certified by the PA or mill
present? (If NO, state in remarks (whichever is applicable), specifying that
portion the missing documents and the deceased was:
inform the claimant to provide the same)  milling at the time of his/her death
(20) Copy of true copy of birth certificate  a small farm cultivator with five (5)
of deceased sugar worker certified by hectares and below directly worked
the LCR/ PSA (stating he/she is the by himself or with the help of
parent of the deceased worker) immediate household members
If claimant is the legitimate sibling: If the claimant is a third party
(22) Are the documentary requirements (31) Are the documentary requirements
mentioned in Item No. 14 and 15 mentioned in Item No. 14 and 15 present?
present? (If NO, state in remarks portion (If NO, state in remarks portion the
the missing documents and inform the missing documents and inform the
claimant to provide the same) claimant to provide the same)

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 DOCUMENT ATTACHED? REMARKS (36) Upon careful review of the documents presented/ submitted and interview with the
YES NO concerned claimant, is the application eligible to receive the SAP death benefit:
If the claimant is a third party  YES and the same will be forwarded to (please state here) for appropriate action
(32) Is the documentary requirement and subsequent consideration for approval by Head of Office/ Regional Director
indicated in Item no. 23 available or  NO and the claimant has been informed of the same. The denial was due to
presented by claimant (if applicable)? (please indicate reason/s):
(33) Is the documentary requirement ______________________________________________________________
indicated in Item no. 30 available or ______________________________________________________________
presented by claimant (if applicable)? ______________________________________________________________
(34) Copy of Joint affidavit by the third PART 4. VERIFICATION
party and waiver of the beneficiary Checked/ Received by : Verified by:
attesting to the fact and circumstances Name Name
of assistance rendered/ extended by the
Position Position
third party to the immediate heir/s of the
deceased and waiving the beneficiary’s Date Date
claim over the benefit Recommending Approval:
(35) Copy of receipt/s of burial Name
expenses certified under oath by the Position
claimant Date

REMINDERS ON THE PROCESSING OF SAP DEATH BENEFIT CLAIMS

A. Action on Claims. A claim for death benefit shall be processed as follows:

1. Filing of claim ‐ the claimant for the death benefit shall use the prescribed form and file claim directly with the
Regional Office, or in its Provincial Offices, accredited Mill and Planters’ Association or
Cooperative through their respective representatives having jurisdiction over the workplace or
residence of the claimant.
2. Application forms shall be made available in the administrative office of Mills and Planters Associations or
Cooperatives to facilitate filing of claim.
3. Processing of claim ‐ the Regional Office’s designated SAP Officer shall immediately process a claim upon receipt
of application form with complete supporting documents, and recommend its approval to the Regional
Director. Accredited Mill and Planters' Association representatives are also authorized to pre‐process claims subject
to final evaluation by the SAP Officer.
4. Action of the Regional Director ‐ the Regional Director shall approve or deny a claim within ten (10) working days
(including field validation) from receipt of the application with complete supporting documents.
5. Payment of claim ‐ payment of approved claim shall be made directly to the claimant within five (5) working days
after approval. The payment of the death benefit shall discharge the Department from any liability with respect to
the amount paid.

B. Appeal in Case of Denial

1. An aggrieved claimant may appeal to the Secretary within fifteen (15) working days from receipt of the
decision or order of denial of the Regional Director on grounds of grave abuse of discretion, gross
incompetence or serious errors in the findings of fact.
2. The Secretary shall decide the appeal within fifteen (15) working days from receipt of such appeal. The decision
of the Secretary is final and unappeasable.

C. Administration of the Sugar Workers' Death Benefit Fund

1. The Department through the Bureau shall administer and manage the SWDBF including all income and
interest in a special trust account in an authorized government depository bank.
2. The Bureau shall provide the SWDB reserve fund to covered regional offices and subsequent release of funds
to the regional offices shall be effected through fund replenishment.

D. Documentation and Reporting. In addition to the required financial reports for liquidation of cash advances on
the SWDBF, the Regional Office shall submit the status of the implementation of the program on a monthly
basis.

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DRAFT COPY (as of June 03, 2022)