x@ubl,.

aI E Phllwinrt
pirupptle HEALTII tNsuRAilcE coRPoRATtoN
Ph[Holth R.llollsl O!f,{rc Vll
ii, ii,i. C,'t*" ir.t l,mt.., C o'lo ,tvc'nr cor F'turu * , C'bn Cttv 6qn
iiii,'ii'* iii-ttio, ).tr-7107, 2J3-3189. 233-32w, 23J'752,' zJt'75 te vwv oN pakh'"ou'ott
LETI'ER OF IITEMBERSTIIP DEACTIVATION

Date
Sir/Madam,

with PhilHoalth Numbcr

* ,,--_, would like to dcactiv ate my fiembership for the reason that:

U I wrruld like to he a daporrJcnt of my spouse/child

trI I can no longer continuc payilrg my prcmium contribution
tr others (pls specify)

Sincercly yours.

Signature ovcr Printcd Nanrc

11.