RF1 FORM- Phil Health

RF-1 REVISED JAN 2002

Republic of the Philippines  PHILIPPINE HEALTH INSURANCE CORPORATION

F O R

EMPLOYER'S QUARTERLY REMITTANCE REPORT

Date Screened:

P H I L H E A L T H

Action Taken:

U S E

Date Screened:

Action Taken:

1

-

PHILHEALTH NO.

-

EMPLOYER TIN

-

By:

-

By: Signature over Printed Name

2

3 COMPLETE EMPLOYER NAME

Signature over Printed Name

EMPLOYER TYPE Regular

COMPLETE MAILING ADDRESS

-

Private

TELEPHONE NO.

4 EMPLOYER'S SSS NO.

Government

-

EMPLOYER'S SSS/GSIS POLICY NO.

5

TYPE OF REPORT

Quarter Ending Mar

200

Addition to previous RF-1

Quarter Ending Jun

200

Deduction to previous RF-1

Quarter Ending Sep

200

Quarter Ending Dec

200

Household 6

7

NAME OF EMPLOYEE/S Surname

PhilHealth ID No./SSS ID No./GSIS M.I. Policy No.

Given Name

9

8 MONTHLY COMPENSATION BRACKET 1st Month

2nd 3rd Month Month

NHIP PREMIUM CONTRIBUTIONS 2nd Month 3rd Month

1st Month PS

ES

PS

ES

PS

APPLICABLE QUARTER

Regular RF-1

10

ES

REMARKS S - Separated, NE - No Earning, NH - Newly Hired

1st Month

2nd Month

3rd Month

Date of  Effectivity

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 11 Month/ onth/Q Quarte uarterr

ME-5 SUMMA RY OF CONTRIB UTION PA YMENTS Total Total Contr Contribu ibutio tion n

ME-5 E-5 Rec Recon oncilationNo.

Date Paid Paid

No. of Employees

12 SUBTOTAL

(PS + ES)

1st Month 2nd Month 3rd Month

13

Certified Correct: SIGNATURE OVER PRINTED NAME

(To be accomplished on every page)

GRAND TOTAL

OFFICIAL DESIGNATION

(PS + ES)

(To be accomplished on every page)

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS THIS FORM

DATE

14

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