This form may be reproduced and is not for sale

Republic of the Philippines

RF-1
PHILIPPINE HEALTH INSURANCE CORPORATION EMPLOYER’S REMITTANCE REPORT
Healthline 441-7444 [Link] FOR PHILHEALTH USE
actioncenter@[Link]
Revised February 2014

1
PHILHEALTH NO. 0 2 1 0 0 0 0 1 9 1 4 3 Date Received: __________________
By: ____________________________
Action Taken:

EMPLOYER TIN 0 0 8 0 1 7 9 9 7 Signature Over Printed Name

2 TRI-SILVER BUILDERS INCORPORATED
COMPLETE EMPLOYER NAME ___________________________________________________________________ 3 EMPLOYER TYPE 4 REPORT TYPE 5 APPLICABLE PERIOD
COMPLETE MAILING ADDRESS __________________________________________________________________
3281 MAGNOLIA STREET ROCKA COMM'L COMPLEX, TABANG PLARIDEL BULACAN
PRIVATE REGULAR RF-1 _________________
__________________________________________________________________ GOVERNMENT ADDITION TO PREVIOUS RF-1
044-7602568
TELEPHONE NO. ______________________________ info@[Link]
EMAIL ADRESS _________________________________ HOUSEHOLD DEDUCTION TO PREVIOUS RF-1
6 7 8 Fill out this portion only if 10 NHIP PREMIUM 11
EMPLOYEES INFORMATION declared employee/s has not 9 CONTRIBUTION EMPLOYEE STATUS
PHILHEALTH IDENTIFICATION NUMBER yet been issued his/her PIN
(PIN) NAME EXT. DATE OF BIRTH SEX MONTHLY S-Separated, NE-No Earnings,
LAST NAME FIRST NAME (SR./JR.) MIDDLE NAME (mm-dd-yyyy)
SALARY PS ES NH-Newly Hired /
(M/F) BRACKET Effectivity Date

1.
1 3 0 2 5 4 7 1 3 1 4 8 MONTES MATT JOEL ALARDE S
2.
2 1 0 2 5 1 3 9 6 4 3 9 PANGILINAN SARA GERONA S
3.
0 1 0 2 5 7 1 9 8 6 0 5 RAMIREZ KAREEN OLIMAN S
4.
1 2 0 5 0 3 8 6 4 3 7 7 TERCERO CAROLINA CABOTAJE S
5.
0 1 0 5 06 20 55 2 8 VICTORINO JUNEDY ANTHONY E. S
NOTHING FOLLOWS
6.

7.

8.

9.

10 .

12 13 14 15 PREPARED BY:
ACKNOWLEDGEMENT RECEIPT (PAR/POR/TRANSACTION REFERENCE NO.) SUBTOTAL (PS + ES)
______________________
__________ (To be accomplished on every page)
SIGNATURE OVER PRINTED NAME
ACKNOWLEDGEMENT
APPLICABLE PERIOD REMITTED AMOUNT TRANSACTION DATE NO. OF EMPLOYEES ______________________
Indicate Total Number of RECEIPT OFFICIAL DESIGNATION
employees per page GRAND TOTAL (PS + ES)
(To be accomplished on every page) __________________
DATE

16
UNDER THE PENALTY OF THE LAW, I HEREBY ATTEST THAT THE ABOVE INFORMATION PROVIDED HEREIN ARE TRUE AND CORRECT.

____________________________________________ ________________________________________ _________________________

Signature over printed name Official Designation Date

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