Вы находитесь на странице: 1из 2

PLEASE READ INSTRUCTION AT THE BACK BEFORE ACCOMPLISHING THIS FORM

  (CHECK APPLICABLE BOX)  
 

(CHECK APPLICABLE BOX)

 
 

PHILHEALTH

INITIAL LIST (Attach to PhilHealth Form Er1)  PHILHEALTH

  PHILHEALTH INITIAL LIST (Attach to PhilHealth Form Er1)
  PHILHEALTH INITIAL LIST (Attach to PhilHealth Form Er1)

REPORT OF EMPLOYEE-MEMBERS

SUBSEQUENT LISTREPORT OF EMPLOYEE-MEMBERS  

 

NAME OF EMPLOYER/FIRM:

 

EMPLOYER NO.

 

ADDRESS:

E-MAIL ADDRESS:

 

PHILHEALTH

     

DATE OF

 

(DO NOT FILL)

 

SSS/GSIS

NAME OF EMPLOYEE

POSITION

SALARY

EMPLOY-

EFF. DATE OF COVERAGE

PREVIOUS EMPLOYER ( IF ANY)

NUMBER

MENT

TOTAL NO. LISTED ABOVE:

     
 

PAGE

OF

SHEETS

 

SIGNATURE OVER PRINTED NAME

TO BE ACCOMPLISHED IN DUPLICATE

Похожие интересы