PLEASE READ INSTRUCTION AT THE BACK BEFORE ACCOMPLISHING THIS FORM

(CHECK APPLICABLE BOX)

PHILHEALTH INITIAL LIST (Attach to PhilHealth Form Er1)
REPORT OF EMPLOYEE-MEMBERS SUBSEQUENT LIST

NAME OF EMPLOYER/FIRM: EMPLOYER NO.

ADDRESS: E-MAIL ADDRESS:

PHILHEALTH DATE OF (DO NOT FILL)
EFF. DATE OF PREVIOUS EMPLOYER
SSS/GSIS NAME OF EMPLOYEE POSITION SALARY EMPLOY-
COVERAGE ( IF ANY)
NUMBER MENT

TOTAL NO. LISTED ABOVE:

PAGE ___ OF ___ SHEETS SIGNATURE OVER PRINTED NAME

TO BE ACCOMPLISHED IN DUPLICATE