DEPENDENT ENROLMENT / CANCELLATION OF ENROLLED DEPENDENT

EMPLOYEE INFORMATION

ID Number
Last Name TUGONON
First Name RAMONICA
Middle Name HERMOSO
Date Hired 1-Dec-19
Position CREDIT VERIFIER
Rank
Unit of Assignment
Civil Status SINGLE

For guidance, the following are the qualified dependents of a regular employee:
A. Married Employee Legitimate spouse without existing health plan
Legitimate and legally adopted children who are unmarried, not more than 21 years old and without existing health plan
Biological parents or adopter, without existing health plan; provided that the employee enrolls all his qualified primary dependents first (i.e., spouse and children)
B. Single Employee Biological parents or adopter without existing health plan
C. Solo Parent Employee Legitimate and legally adopted children who are unmarried, not more than 21 years old and without existing health plan
Biological parents or adopter, without existing health plan; provided that the employee enrolls all his children first.

DEPENDENT FOR ENROLMENT (name to appear on card)

RELATIONSHIP TO
LAST NAME FIRST NAME MIDDLE NAME GENDER BIRTH DATE AGE CIVIL STATUS
EMPLOYEE

TUGONON ROSA MARIA HERMOSO FEMALE 22-Mar-60 MARRIED MOTHER

TUGONON RAMON DANIELES MALE 22-Mar-56 MARRIED FATHER

DEPENDENT FOR CANCELLATION

RELATIONSHIP TO REASON FOR
LAST NAME FIRST NAME MIDDLE NAME GENDER BIRTH DATE AGE CIVIL STATUS
EMPLOYEE CANCELLATION

I hereby certify that all information provided herein are true and correct and that each enrolled dependent has no existing health plan.

Signature
Date signed