Please upload the following to this Task

• Accomplished Philippine Health Insurance Corporation (PHIC) Member Data Record Form and kindly
upload your Philhealth ID

Note: This is a required pre-employment document, please accomplish within two (2) week
 (CHECK APPLICABLE BOX)
PHILHEALTH
REPORT OF EMPLOYEE-MEMBER
INITIAL LIST (Attach to PhilHealth Form Er1)
SUBSEQUENT LIST Er2
NAME OF EMPLOYER/FIRM DCX PH INC. EMPLOYER NO. 00-700002076-9
ADDRESS: 2nd Floor Metro Supermarket, Marquee Mall, Nepo Avenue, Brgy. Pulung Maragul, Angeles City, Pampanga, 2009 E-MAIL ADDRESS: kyrah.aquilizan@delegatecx.com
(DO NOT FILL)
DATE OF PREVIOUS EMPLOYER (IF
PHILHEALTH SSS/GSIS NAME OF EMPLOYEE POSITION SALARY EFF. DATE OF
EMPLOYMENT ANY)
NUMBER COVERAGE

TOTAL NO. LISTED ABOVE:

KYRAH FAITH AQUILIZAN
PAGE___ OF___ SHEETS SIGNATURE OVER PRINTED NAME