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PLEASE READ INSTRUCTIONS AT THE BACK BEFORE ACCOMPLISHING THIS FORM.
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PHILHEALTH
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REPORT OF EMPLOYEE - MEMBERS
(CHECK APPLICABLE BOX)
 INITIAL LIST
(Attach to PhilHealth Form Er1)
SUBSEQUENT LIST
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NAME OF EMPLOYER/FIRM:
Employer No:
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ADDRESS:
E-MAIL ADDRESS:
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(DO NOT FILL)
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PHILHEALTH/SSS/GSISNAME OF EMPLOYEEPOSITIONSALARYDATE OFEFF. DATE OFPREVIOUS EMPLOYER
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NUMBEREMPLOYMENTCOVERAGE( IF ANY )
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TOTAL NO. LISTED ABOVE:
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PAGE_1__ OF__1__SHEETSSIGNATURE OVER PRINTED NAME
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TO BE ACCOMPLISHED IN DUPLICATE.
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Note: This form can be reproduced but not for sale.
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