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RF1 Employer's Remittance Report
PhilHealth report form for employer's remittance
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: This form may be reproduced and is NOT FOR SALE
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
RF-1
EMPLOYER’S REMITTANCE REPORT
Healthline 441 7444 www.philhealth.gov.ph
actioncenter@philhealth.gov.ph
FOR PHILHEALTH USE
Revised February 2014
1
Date Received:
By:
PHILHEALTH NO.
EMPLOYER TIN
2
Action Taken:
Signature Over Printed Name
3
COMPLETE EMPLOYER NAME
EMPLOYER TYPE
REPORT TYPE
4
PRIVATE
5
REGULAR RF-1
COMPLETE MAILING ADDRESS
GOVERNMENT
TELEPHONE NO.
,
6
DEDUCTION TO PREVIOUS RF-1
EMPLOYEE/S INFORMATION
7
PHILHEALTH IDENTIFICATION NUMBER
(PIN)
ADDITION TO PREVIOUS RF-1
HOUSEHOLD
EMAIL ADDRESS
LAST NAME
FIRST NAME
Fill-out this portion only if
declared employee/s has not
yet been issued his/her PIN
8
NAME EXT.
(Sr./Jr.)
APPLICABLE
PERIOD
MIDDLE NAME
DATE OF BIRTH
(mm-dd-yyyy)
SEX
(M/F)
9
MONTHLY
SALARY
BRACKET
(MSB)
10
NHIP PREMIUM
CONTRIBUTION
PS
11
EMPLOYEE STATUS
S-Separated, NE-No Earnings,
NH-Newly Hired /
ES
Effectivity Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10
.
12
13
14
ACKNOWLEDGEMENT RECEIPT (PAR/POR/TRANSACTION REFERENCE NO.)
APPLICABLE PERIOD
REMITTED AMOUNT
ACKNOWLEDGEMENT
RECEIPT NO.
TRANSACTION DATE
NO. OF EMPLOYEES
Indicate Total Number of
employees per page
SUBTOTAL
15
(PS + ES)
PREPARED BY:
(To be accomplished on every page)
SIGNATURE OVER PRINTED NAME
GRAND TOTAL
(PS + ES)
OFFICIAL DESIGNATION
(To be accomplished on every page)
16
DATE
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
17
PAGE
OF
PAGE/S
INSTRUCTIONS
Note: Instructions for each numbered box are enumerated below:
NHIP MONTHLY PREMIUM CONTRIBUTION SCHEDULE FOR 2014
MSB
Monthly Salary Range
Salary Base (SB)
Total Monthly
Contribution
Personal Share Employer Share
(PS)
(ES)
BOX 4
BOX 5
BOX 6
BOX 7
BOX 8
BOX 9
BOX 10
1
8,999.99 and below
8,000.00
200.00
100.00
2
9,000.00 to 9,999.99
9,000.00
225.00
112.50
112.50
3
10,000.00 to 10,999.99
10,000.00
250.00
125.00
125.00
4
11,000.00 to 11,999.99
11,000.00
275.00
137.50
137.50
5
12,000.00 to 12,999.99
12,000.00
300.00
150.00
150.00
6
13,000.00 to 13,999.99
13,000.00
325.00
162.50
162.50
Write the COMPLETE Employer Name, Mailing Address , Telephone Number and Email Address ( DO NOT ABBREVIATE).
Check applicable box for the EMPLOYER TYPE.
7
14,000.00 to 14,999.99
14,000.00
350.00
175.00
175.00
8
15,000.00 to 15,999.99
15,000.00
375.00
187.50
187.50
9
16,000.00 to 16,999.99
16,000.00
400.00
200.00
200.00
10
17,000.00 to 17,999.99
17,000.00
425.00
212.50
212.50
11
18,000.00 to 18,999.99
18,000.00
450.00
225.00
225.00
12
19,000.00 to 19,999.99
19,000.00
475.00
237.50
237.50
13
20,000.00 to 20,999.99
20,000.00
500.00
250.00
250.00
14
21,000.00 to 21,999.99
21,000.00
525.00
262.50
262.50
15
22,000.00 to 22,999.99
22,000.00
550.00
275.00
275.00
16
23,000.00 to 23,999.99
23,000.00
575.00
287.50
287.50
17
24,000.00 to 24,999.99
24,000.00
600.00
300.00
300.00
18
25,000.00 to 25,999.99
25,000.00
625.00
312.50
312.50
19
26,000.00 to 26,999.99
26,000.00
650.00
325.00
325.00
20
27,000.00 to 27,999.99
27,000.00
675.00
337.50
337.50
28,000.00 to 28,999.99
28,000.00
700.00
350.00
350.00
22
29,000.00 to 29,999.99
29,000.00
725.00
362.50
362.50
23
30,000.00 To 30,999.99
30,000.00
750.00
375.00
375.00
24
BOX 2
BOX 3
Write the complete PHILHEALTH NUMBER and EMPLOYER TIN in the corresponding boxes. “ If without PEN, employers may register with the Philippine Business
Registry (PBR) and the Corporation shall no longer require submission of documents. However, should the employer be unable to register through the PBR, it shall
be required to attach a duly accomplished ER1 form and any of the following documents, whichever is applicable:
a. For single proprietorships – Department of Trade and Industry (DTI) registration;
b. For partnerships and corporations – Securities and Exchange Commission (SEC) registration;
c. For foundations and other non‐profit organizations – SEC registration;
d. For cooperatives – Cooperative Development Authority (CDA) registration;
e. For backyard industries/ventures and micro‐business enterprises – Barangay Certification and/or Mayor‟s Permit.
21
BOX 1
31,000.00 to 31,999.99
31,000.00
775.00
381.50
381.50
Check 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”, whichever is applicable. 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).
Always 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 PAR/POR/Transaction Reference Number.
Indicate the corresponding PHILHEALTH IDENTIFICATION NUMBER (PIN) opposite the respective names of your employees. For initial registration or updating of
member data record and/or declaration of dependents, require the employee/s to properly accomplish the PhilHealth Member Registration Form (PMRF). The
employer shall be required to submit the same together with the Employment Report Form (ER2) duly signed by the employer to facilitate registration and
updating of the membership data record of such employee/s.
Print names of Employees in alphabetical order. Write the complete name of each employee by providing the Last Name, First Name, Name Extension (Sr., Jr.,
or II, III, if there be any) and Middle Name (Leave Blank for employee without Middle Name). Do not skip lines when listing down their names. Write “NOTHING
FOLLOWS” on the line immediately following the last listed employee.
In case that the employee/s listed in the submitted RF‐1 has not yet been issued his/her permanent PIN, indicate his/her DATE OF BIRTH and SEX in the column
provided to facilitate the immediate assignment and generation of PIN. Otherwise, leave the column blank and ensure that the PIN/s in box no. 6 is/are correctly
indicated.
Indicate the employees’ respective MONTHLY SALARY BRACKET (MSB) corresponding to the MONTHLY SALARY RANGE where the employee’s monthly salary
falls. Please refer to the NHIP MONTHLY PREMIUM CONTRIBUTION SCHEDULE on the right for your reference. Corresponding MSB not filled‐out shall mean that
such employee’s compensation for the particular period shall belong to the highest bracket.
25
32,000.00 to 32,999.99
32,000.00
800.00
400.00
400.00
26
33,000.00 to 33,999.99
33,000.00
825.00
412.50
412.50
Indicate 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.
27
34,000.00 to 34,999.99
34,000.00
850.00
425.00
425.00
28
35,000.00 and up
35,000.00
875.00
437.50
437.50
BOX 11 In the “EMPLOYEE STATUS” column indicate the letter – “S” if the employee is Separated, “NE” if with No Earnings and “NH” if employee is Newly Hired.
Supply the Date of effectivity in the column provided.
BOX 12 Indicate total number of employee/s listed in the submitted RF‐1. Ensure that the total number of employees’ listed in box no. 7 shall correspond to the
number of employees in box no. 12.
BOX 13
100.00
Supply needed information on the “ACKNOWLEDGEMENT RECEIPT (PAR/POR/Transaction Reference Number)” boxes. Indicate in the corresponding box the
“Applicable Period”, “Remitted Amount”, “Acknowledgement Receipt Number”, “Transaction Date” and “Number of Employees”.
BOX 14
Add all contribution in the PERSONAL SHARE (PS) column and EMPLOYER SHARE (ES) column for the applicable month and reflect the sum in the “SUBTOTAL” box
for each page, if more than one (1) page, thereafter, add all subtotals/page totals and reflect the sum in the “GRAND TOTAL” box in the last sheet of the
accomplished RF‐1 to indicate total amount of contributions paid for the said applicable month.
BOX 15
Affix signature over complete printed name of the authorized officer preparing the report, his/her official designation and date.
BOX 16
Affix signature over complete printed name of the authorized officer certifying the report, his/her designation and date.
BOX 17
Always indicate correct page number and the total number of pages for each form.
COPY DISTRIBUTION
Form
RF‐1
PAR
No. of Copies
2
4
1st
PHIC
PAYOR
2nd
PAYOR
COLLECTING AGENT’S
COPY
3rd
X
PHIC
REMINDERS:
4th
X
PHIC
Submit original copy of this duly accomplished form with the corresponding copies of the validated PAR/POR/Transaction
Reference Number to the Collection Section/Unit of the respective PhilHealth Regional or Local Health Insurance Office
within five (5) days after payment. The schedule for the payment of contributions is on the 11th to 15th day for employers
with PENs ending in 0‐4; and 16th to 20th day for employers with PENs ending in 5‐9 following the applicable month. As
provided for under Section 18, Rule III, Title III of the Implementing Rules and Regulations (IRR) of National Health
Insurance Act of 2013, the failure of the employer to remit the required contribution and to submit the required
remittance list shall make the employer liable for reimbursement of payment of a properly filed claim in case the
concerned employee or dependent/s avails of Program benefits, without prejudice to the imposition of other penalties.
THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE
