Share

PPS-HEUR1 Household Employer Unified Registration Form

PhilHealth application form for household employer

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: PPS-HEUR1 FORM (V.1)
Republic of the Philippines

HOUSEHOLD EMPLOYER
UNIFIED REGISTRATION FORM
(Pursuant to R.A. 10361 or the "Batas Kasambahay")
PLEASE READ THE INSTRUCTIONS BELOW BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK OR BLUE INK
.ONLY. (Basahin ang mga Instructions sa ibaba ng Form bago ito sulatan. Isulat ang lahat ng impormasyon sa MALALAKING TITIK at gumamit lamang ng ITIM o ASUL na
. tinta.)

PART I - PLEASE INDICATE YOUR EMPLOYER / MEMBERSHIP NUMBER IF ALREADY REGISTERED
(Paki lagay ang inyong numero sa Pag-IBIG, PhilHealth or SSS kung myembro na)

Pag-IBIG HOUSEHOLD EMPLOYER NUMBER/
REGISTRATION TRACKING NUMBER (RTN)

PHILHEALTH EMPLOYER NUMBER (PEN)

SSS HOUSEHOLD EMPLOYER ID NUMBER

PART II - A. PERSONAL INFORMATION
NAME

LAST NAME
(Apelyido)

FIRST NAME
(Pangalan)

Day

Year

(Tirahan)

MALE

UNIT/RM./FLR. NO.
(Bilang ng Yunit at Palapag)

(Babae)

BUILDING NAME
(Pangalan ng Gusali)

BARANGAY/DISTRICT
(Barangay/Distrito)

LOT/BLK./HOUSE NO.
(Bilang ng Lote, Bloke, Bahay)

STREET NAME
(Kalye)

MUNICIPALITY/CITY
(Munisipyo/Syudad)

TELEPHONE NUMBER (AREA CODE+TEL. NO.)

CHECK IF NO MIDDLE NAME
(I-tsek ang kahon kung walang
gitnang pangalan)

FEMALE

(Lalake)

ADDRESS

MIDDLE NAME
(Gitnang Pangalan)

TAX IDENTIFICATION NUMBER (IF ANY)

SEX (Kasarian)

DATE OF BIRTH (Araw ng Kapanganakan)
Month

NAME EXTENSION
(Ex. Jr. / II)

MOBILE/CELLPHONE NUMBER

SUBDIVISION
(Subdibisyon)

PROVINCE/REGION
(Probinsya/Rehiyon)

E-MAIL ADDRESS

ZIP CODE

NUMBER OF KASAMBAHAY/S
(Bilang ng Kasambahay)

PART II - B. CERTIFICATION
I hereby certify that the information supplied above are true and correct for the purpose of my registration in the three (3) social security
agencies of the Philippine Government, namely, Pag-IBIG, PhilHealth & SSS, as Household Employer.
(Ako ay nagpapatunay na ang aking mga isinaad sa itaas ay totoo at tama na nararapat para ako ay ma-rehistro bilang Household Employer sa programa ng Pag-IBIG, PhilHealth at SSS.)

SIGNATURE OVER PRINTED NAME OF HOUSEHOLD EMPLOYER

DATE

PART III - TO BE FILLED OUT BY Pag-IBIG/PHILHEALTH/SSS
RECEIVED BY

Pag-IBIG

PHILHEALTH

SIGNATURE OVER PRINTED NAME

SSS

DATE & TIME

BRANCH

EVALUATED BY

FOR PHILHEALTH USE

SIGNATURE OVER PRINTED NAME

DATE & TIME

PART IV - CERTIFICATION BY RECEIVING AGENCY (If filed through an Authorized Representative)
This is to certify that a Letter of Authorization from the Household Employer was presented and that the signature was verified based on the
valid ID presented.

SIGNATURE OVER PRINTED NAME OF
AUTHORIZED OFFICER OF RECEIVING AGENCY
INSTRUCTIONS

DATE / TIME

1. If filed/submitted personally by the Household Employer, no supporting document is required to be submitted.
2. If duly accomplished Form is filed/submitted through an Authorized Representative of the Household Employer, presentation of the following
is required:
- Letter of Authorization from Household Employer
- Valid ID of the Household Employer
- Valid ID of the Authorized Representative
3. Update/s or Change/s in the Employer Information should be submitted to each of the 3 Agencies - Pag-IBIG, PhilHealth and SSS.

THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE
 
Page of
Share