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PLEASE READ INSTRUCTION AT THE BACK BEFORE ACCOMPLISHING THIS FORM

NAME OF EMPLOYER/ FIRM:

ADDRESS:

NAME OF EMPLOYEE POSITION SALARY

TOTAL NO. LISTED ABOVE:

PAGE ____OF ______ SHEETS SIG

PHILHEALTH/SSS/GSIS NUMBER

DATE OFEMPLOYEMENT

PHILHEALTH

REPORT OF EMPLOYEE-MEMBERS

(CHECK APPLICABLE BOX)

INITIAL LIST (Atta!"# t$ P!%&!"a&t! F$' E')

SUBSE*UENT LIST

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TO BE ACCOMPLISHED IN DUPLICATE

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EMPLOYER NO.

PREVIOUS EMPLOYER (IF ANY)

ATURE OVER PRINTED NAME

(DO NOT FILL)EFF.DATE OF

COVERAGE

Er2

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