<COMPANY NAME>

<PEN>
<ADDRESS>
<EMAIL ADDRESS/ CONTACT NO>

<DATE>

Mr. ALBERTO C. MANDURIAO

Branch Manager
Philhealth Insurance Corporation
PRO NCR North
Caloocan City

Re: Request for Certificate of Exemption from Online Payment

Sir,

Good day!

In line with the Philhealth Circular No. 2020-008- Payment of Premium Contributions through
the Online Payment Facility of the Electronic Premium Remittance System (EPRS), may we
request the issuance of Certificate of Exemption due to the following reasons:

 Employer office location has an unstable connection or no internet provider.

 Employer office located outside the 10km radius from nearest ACAs with online facility
interlinked to EPRS
 Currently working for Online Payment/ Bank enrollment on process
 Other reasons:
________________________________________________________________________
________________________________________________________________________

Hoping for your kind consideration and approval to our request. Thank you.

Yours truly,

Name & Signature

Designation