Visio Er2

User Manual: ER2

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NAME OF EMPLOYER/FIRM:

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

ADDRESS: E-MAIL ADDRESS:

EMPLOYER NO.

TOTAL NO. LISTED ABOVE:

SIGNATURE OVER PRINTED NAMEPAGE ___ OF ___ SHEETS

TO BE ACCOMPLISHED IN DUPLICATE

PHILHEALTH

SSS/GSIS

NUMBER NAME OF EMPLOYEE POSITION SALARY DATE OF

EMPLOY-

MENT

(DO NOT FILL)

EFF. DATE OF

COVERAGE PREVIOUS EMPLOYER

( IF ANY)