Visio Er2

User Manual: ER2

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PLEASE READ INSTRUCTION AT THE BACK BEFORE ACCOMPLISHING THIS FORM

PHILHEALTH
REPORT OF EMPLOYEE-MEMBERS

(CHECK APPLICABLE BOX)
INITIAL LIST (Attach to PhilHealth Form Er1)
SUBSEQUENT LIST

NAME OF EMPLOYER/FIRM:

EMPLOYER NO.

ADDRESS:
PHILHEALTH
SSS/GSIS
NUMBER

E-MAIL ADDRESS:
NAME OF EMPLOYEE

POSITION

SALARY

DATE OF
EMPLOYMENT

(DO NOT FILL)
EFF. DATE OF
COVERAGE

PREVIOUS EMPLOYER
( IF ANY)

TOTAL NO. LISTED ABOVE:
PAGE ___ OF ___ SHEETS

TO BE ACCOMPLISHED IN DUPLICATE

SIGNATURE OVER PRINTED NAME
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