PLEASE READ INSTRUCTIONS AT THE BACK BEFORE ACCOMPLISHING THIS FORM.

PHILHEALTH
REPORT OF EMPLOYEE - MEMBERS (CHECK APPLICABLE BOX) INITIAL LIST (Attach to PhilHealth Form Er1) SUBSEQUENT LIST
ER2
NAME OF EMPLOYER/FIRM: MUNICIPALITY OF PINAMALAYAN Employer No: 150952000001
ADDRESS: MADRID BLVD., ZONE III, PINAMALAYAN, ORIENTAL MINDORO E-MAIL ADDRESS:
(DO NOT FILL)
PHILHEALTH/SSS/GSIS NAME OF EMPLOYEE POSITION SALARY DATE OF EFF. DATE OF PREVIOUS EMPLOYER
NUMBER EMPLOYMENT COVERAGE ( IF ANY )
Surname Given name Middle name

TOTAL NO. LISTED ABOVE: CERTIFIED CORRECT:

One (1)
NEMIA B. MONSANTO
Administrative Officer V / HRMO III
PAGE_1__ OF __1__SHEETS SIGNATURE OVER PRINTED NAME
TO BE ACCOMPLISHED IN DUPLICATE.
Note: This form can be reproduced but not for sale.