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PhilHealth Form Er2

This document is a PhilHealth report form for employers to list their employee members. It requests information such as the employer's name and address, each employee's name, position, salary, date of employment, effective date of PhilHealth coverage, previous employer, and a total number and signature of the certifying employer. Instructions are provided on the back of the form.

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ludwig
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3K views3 pages

PhilHealth Form Er2

This document is a PhilHealth report form for employers to list their employee members. It requests information such as the employer's name and address, each employee's name, position, salary, date of employment, effective date of PhilHealth coverage, previous employer, and a total number and signature of the certifying employer. Instructions are provided on the back of the form.

Uploaded by

ludwig
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • PhilHealth Employee Report Form

PLEASE READ INSTRUCTIONS AT THE BACK BEFORE ACCOMPLISHING THIS FORM.

PHILHEALTH
REPORT OF EMPLOYEE - MEMBERS

NAME OF EMPLOYER/FIRM:
(CHECK APPLICABLE BOX) INITIAL LIST (Attach to PhilHealth Form Er1) SUBSEQUENT LIST

Employer No:
Er2
ADDRESS: E-MAIL ADDRESS:
(DO NOT FILL)
PHILHEALTH/SSS/GSIS NAME OF EMPLOYEE POSITION SALARY DATE OF EFF. DATE OF PREVIOUS EMPLOYER
NUMBER EMPLOYMENT COVERAGE ( IF ANY )
Surname Given name Middle name

TOTAL NO. LISTED ABOVE: CERTIFIED CORRECT:


One (1)

PAGE_1__ OF __1__SHEETS SIGNATURE OVER PRINTED NAME


TO BE ACCOMPLISHED IN DUPLICATE.
Note: This form can be reproduced but not for sale.
Er2

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