Virginia Food Inc. Rev. No.

04 HRA-HRDS-FORM-06
HR SERVICES SECTION Revision
Sitio Younglife, Cogon, Compostela, Cebu Effectivity Date:
Date:

Human Resource Department

HMO ENROLLMENT OF 28JUL2022 01AUG2022
DEPENDENTS

Company: Godspeed Megamerchants Co.,

ID Number: 950422
Inc.

Name of Employee: Mario Cabuyao Alipar Civil Status: Married

Birthday: 1/29/1995 Enrollment Date: 3/3/2024 20:28:55

Rank: Rank & File to Supervisor Trainee

RULING ON QUALIFIED DEPENDENTS:

(Please take note that you must follow exact hierarchy/order based on the priority of enrollment stated below)

For UNMARRIED Principal Members: For MARRIED Principal Members:

FIRST PRIORITY TO ENROLL: FIRST PRIORITY TO ENROLL:
Naturally acknowledged child below 21 yrs. old Legitimate spouse not over 65 yrs. old
SECOND PRIORITY TO ENROLL: SECOND PRIORITY TO ENROLL: Unmarried and
Parents not over 65 years old unemployed child below 21 yrs. old
THIRD PRIORITY TO ENROLL:
Unmarried and unemployed sibling below 21 yrs. old

DEPENDENT/S FULL NAME RELATIONSHIP TO CIVIL

DATE OF BIRTH GENDER
(first, middle, last) PRINCIPAL STATUS
Anna Nerie Aliganga Alipar Legal Spouse 1/25/0092 Married Female
Sanjay Aliganga Alipar Child 7/16/2023 Single Male

AUTHORITY TO DEDUCT

This is to confirm that the above-listed name(s) is/are the dependent(s) I will enroll for my health care plan. I hereby authorize
Virginia Food, Inc. to deduct from my salary the corresponding premiums:

Dependent/s Room & Board Accommodation:

Pay ward Room for TWO (2) or MORE DEPENDENTS (Php 649.78/payroll)

A. For ONE (1) DEPENDENT ONLY: Quarterly Rate Deduction per Payroll

Option 1:Payward 2,729.44 454.90

Option 2: Regular Private Room 2,858.24 476.37

B. For TWO (2) or MORE DEPENDENTS:

Option 1: Payward 3,898.72 649.78

Option 2: Regular Private Room 5,423.04 903.84

Mario Cabuyao Alipar

Signature Over Printed Name

Reproduction, photocopying, storage or transmission by magnetic or electronic means is strictly

prohibited by law. Neither the document nor the information contained therein may be
reproduced or disclosed without written consent by the Human Resource Manager.
This document is referred to as:
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