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Republic of the Philippines for sale

R F
PHILIPPINE HEALTH INSURANCE CORPORATION EMPLOYER’S REMITTANCE
REPORT
Healthline 441-7444 www.philhealth.gov.ph FOR PHILHEALTH USE
Revised Feb actioncenter@philhealth.gov.ph

- 1
ru ary 2 014
Date Received:
Taken: By:
Signature Over Printed Name
Action

1
PHILHEALTH
NO.
EMPLOYER
TIN
2 COMPLETE EMPLOYER NAME 3
EMPLOYER 4
REPORT TYPE 5
APPLICABLE PERIOD
TYPE
COMPLETE MAILING ADDRESS REGULAR RF-1
PRIVATE ADDITION TO PREVIOUS
TELEPHONE NO. EMAIL ADRESS GOVERNME RF-1 DEDUCTION TO
NT PREVIOUS RF-1
HOUSEHOL
D
6 7 8 Fill out this portion 10 NHIP PREMIUM
EMPLOYEES only if declared 11 EMPLOYEE STATUS
PHILHEALTH IDENTIFICATION NUMBER
INFORMATION employee/s has not yet
9 CONTRIBUTION
been issued his/her PIN
(PIN) NAME DATE OF SE MONTHLY S-Separated, NE-No
LAST FIRST EXT. MIDDLE BIRTH
SALARY PS Earnings, NH-
X ES Newly Hired /
NAME NAME (SR./JR.) NAME (mm-dd- (M/F) BRACKET Effectivity Date
yyyy)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10 .

12 13 14 15 PREPARED BY:
ACKNOWLEDGEMENT RECEIPT (PAR/POR/TRANSACTION REFERENCE SUBTOTAL (PS + ES)
NO.) (To be accomplished on every page)
SIGNATURE OVER PRINTED

ACKNOWLEDGEM NAME OFFICIAL DESIGNATION

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM