Philhealth Form RF-1 PDF form, Free download.

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Form Name:   Philhealth Form RF-1
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Date:   4/17/2011
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PHILHEALTH NO.EMPLOYER TINFOR PHILHEALTH USECOMPLETE EMPLOYER NAME COMPLETE MAILING ADDRESS TELEPHONE NO.REVISED JAN 20081Date Received:Action Taken:By:23EMPLOYER TYPEPRIVATEGOVERNMENTHOUSEHOLD4 REPORT TYPEREGULAR RF-1ADDITION TO PREVIOUS RF-1DEDUCTION TO PREVIOUS RF-15APPLICABLE PERIOD6NAME OF EMPLOYEE/SSURNAMEGIVEN NAME11ACKNOWLEDGEMENT RECEIPT (ME-5/POR/OR/PAR)PHILHEALTH NO. SUBTOTAL (PS + ES)(To be accomplished on every page) GRAND TOTAL (PS + ES)STATUS12SIGNATURE OVER PRINTED NAMEOFFICIAL DESIGNATIONDATE14PAGEPAGESOFPLEASE READ INSTRUCTIONS ( FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM13PHILIPPINE HEALTH INSURANCE CORPORATIONEMPLOYER’S REMITTANCE REPORT8MONTHLY SALARY BRACKET(MSB)PSESSignature Over Printed NameNO.MIDDLE NAME200Republic of the Philippines(To be accomplished on the last page)1.2.3.4.5.6.7.8.9.10.11.12.13.14.15.NHIP PREMIUM CONTRIBUTIONMEMBER STATUSS-Separated, NE-No Earnings, NH-Newly HiredCERTIFIED CORRECTREMITTED AMOUNTTRANSACTION DATEAPPLICABLE PERIODACKNOWLEDGEMENT RECEIPT NO.NO. OF EMPLOYEES7910NOTE: Instructions for each numbered box are enumerated belowBOX 1Write the complete Employer TIN and PHILHEALTH NO. in corresponding boxes. “if without PEN, the employer shall be required to attach duly accomplished ER1 form and any of the following documents, whichever is applicable to facilitate registration and PEN issuance:Write the COMPLETE Employer Name, Address and Telephone No. (DO NOT ABBREVIATE)BOX 2BOX 3Check applicable box for the Employer Type.BOX 4Check the applicable box for the Report Type. For adjustment on remittance report on previous month, use a separate RF-1 form and check the box corresponding to "Addition to Previous RF-1" or "Deduction to Previous RF-1" as the case maybe. Write only the names of the employees with erroneous contributions and the difference between the correct amount and the amount that was previously reported. If an underpayment results due to correction, please remit the amount due to PhilHealth. Use separate/different sets of RF-1 form for each month when reporting previous payments or late payments made on previous month(s).PPPPPMSBMonthly Salary RangeSalary Base (SB)Personal Share(PS)Employer Share(ES)NHIP MONTHLY PREMIUM CONTRIBUTION SCHEDULE Total Monthly ContributionCOPY DISTRIBUTIONFormNo. of Copies1st2nd3rd4thRF-1ME-524PHICPAYORPAYORPHICPHICXXBANKDEADLINE OF SUBMISSION OF FORMSEvery 15th day after the applicable monthTHIS FORM MAY BE REPRODUCEDBOX 5Always indicate the applicable month and year of premium contributions paid. The month and year coverage in the RF-1 should correspond with the month and year coverage indicated in the ME-5 /OR/POR/PAR.BOX 6Print names of Employees in alphabetical order; write Family Name first; Given Name and Middle Name as they pronounced. For instance, the names JULIAN SALVADOR DELA CRUZ , LILIA BERNARDO DELOS SANTOS. and MARIA LAGDAMEO DE GUIA should be written as DELA CRUZ, JULIAN SALVADOR; DELOS SANTOS LILIA BERNARDO; and DE GUIA MARIA LAGDAMEO; also, names with suffixes such as Jr., Sr., III, etc. should always be written after the family name. Do not skip lines when listing down theIr names. Write "NOTHING FOLLOWS" on the line immediately following the last listed employee.BOX 7Indicate the corresponding PhilHealth Identification No. (PIN) opposite the respective names of your employees. IF WITHOUT PIN, The employer shall be required to attach the properly accomplished Registration Forms (M1a) including the supporting document/s for declared dependent/s if any and ER2s to faciliate PIN issuance and registration.BOX 8Indicate your employees' respective Monthly Salary Bracket (MSB) corresponding to the Monthly Salary Range where the employee’s monthly salary falls. Please refer to the Monthly Premium Contribution Schedule for your reference. Corresponding MSB left unaccomplished shall mean that the employee’s compensation for the particular period shall belong to the highest bracket.BOX 9Indicate the corresponding Personal Share (PS) and Employer Share (ES) on the boxes provided for each remittance. The total premium contribution (PS + ES) for the month must fall within the prescribed bracket. BOX 10In the "Member Status" column indicate the "S" if the employee is separated, "NE" if with no earnings and "NH" if employee is newly hired. BOX 11Supply needed information on the "ACKNOWLEDGEMENT RECEIPTS (ME-5/POR/OR/PAR)" boxes. Indicate in the corresponding box the acknowledgement receipts no. (i.e ME-5 Reconciliation No., found in the lower left portion of the ME-5 form for the month. Total Monthly Premium to be indicated opposite the applicable month coverage in the ME-5/POR/OR/PAR should also tally with the amount reflected in the RF-1). BOX 12Add all contribution in the Personal Share (PS)column and Employer Share (ES)column, for each month and reflect the sum in the "Subtotal"box for each page. Consequently, add all subtotals/page totals and reflect sum in the "Grand Total"box in the last sheet of the accomplished RF-1 to indicate total amount of contributions paid for the applicable month.BOX 13Affix signature and print complete name, designation and date of certification of authorized officer certifying the report.BOX 14Always indicate page number and total number of pages at each of the form.I N S T R U C T I O N S1. Business License Permit for single proprietorship;2. SEC Registration for a partnership and Corporation;3. License to Operate for all employers.14,999.99 and below4,000.00100.0050.0050.0025,000.00 to 5,999.995,000.00125.0062.5062.5036,000.00 to 6,999.996,000.00150.0075.0075.0047,000.00 to 7,999.997,000.00175.0087.5087.5058,000.00 to 8,999.998,000.00200.00100.00100.0069,000.00 to 9,999.999,000.00225.00112.50112.50``710,000.00 to 10,999.9910,000.00250.00125.00125.00811,000.00 to 11,999.9911,000.00275.00137.50137.50912,000.00 to 12,999.9912,000.00300.00150.00150.001013,000.00 to 13,999.9913,000.00325.00162.50162.501114,000.00 to 14,999.9914,000.00350.00175.00175.001215,000.00 to 15,999.9915,000.00375.00187.50187.501316,000.00 to 16,999.9916,000.00400.00200.00200.001417,000.00 to 17,999.9917,000.00425.00212.50212.501518,000.00 to 18,999.9918,000.00450.00225.50225.501619,000.00 to 19,999.9919,000.00475.00237.50237.501720,000.00 to 20,999.9920,000.00500.00250.00250.001821,000.00 to 21,999.9921,000.00525.00262.50262.501922,000.00 to 22,999.9922,000.00550.00275.00275.002023,000.00 to 23,999.9923,000.00575.00287.50287.502124,000.00 to 24,999.9924,000.00600.00300.00300.002225,000.00 to 25,999.9925,000.00625.00312.50312.502326,000.00 to 26,999.9926,000.00650.00325.00325.002427,000.00 to 27,999.9927,000.00675.00337.50337.502528,000.00 to 28,999.9928,000.00700.00350.00350.002629,000.00 to 29,999.9929,000.00725.00362.50362.502730,000.00 and up30,000.00750.00375.00375.00Submit Original Copy of this duly accomplished form with the corresponding copies of the validated ME-5/ OR/POR/ PAR to the Collection Section of the respective NCR-Service Offices for payors within the NCR or to Service Offices (SOs)/PhilHealth Regional Offices (PROs) for payors outside NCR. The Duplicate copy of this form shall be the Payor’s Copy. Deadline of payment contributions shall be on the 10th day after the applicable month. Employers who fail to comply with the above requirements shall be subjected to the penalties provided under Article X, R.A.7875