This form may be reproduced and is NOT FOR SALE

Republic of the Philippines

RF-1

EMPLOYERS REMITTANCE REPORT

Healthline 441 7444 www.philhealth.gov.ph

FOR PHILHEALTH USE

Revised February 2014

Date Received:
By:

PHILHEALTH NO.
EMPLOYER TIN

Action Taken:
Signature Over Printed Name

COMPLETE EMPLOYER NAME

EMPLOYER TYPE

REPORT TYPE

PRIVATE

COMPLETE MAILING ADDRESS

TELEPHONE NO.

GOVERNMENT

ADDITION TO PREVIOUS RF-1

HOUSEHOLD

DEDUCTION TO PREVIOUS RF-1

EMPLOYEE/S INFORMATION

7
PHILHEALTH IDENTIFICATION NUMBER
(PIN)

EMAIL ADDRESS

LAST NAME

FIRST NAME

Fill-out this portion only if

NAME EXT.
(Sr./Jr.)

REGULAR RF-1

MIDDLE NAME

DATE OF BIRTH
(mm-dd-yyyy)

SEX
(M/F)

9
MONTHLY
SALARY
BRACKET
(MSB)

10

NHIP PREMIUM
CONTRIBUTION

PS

11

APPLICABLE
PERIOD

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.)

REMITTED AMOUNT

ACKNOWLEDGEMENT
RECEIPT NO.

TRANSACTION DATE

NO. OF EMPLOYEES

Indicate Total Number of

SUBTOTAL

15

(PS + ES)

PREPARED BY:

(To be accomplished on every page)

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:Instructionsforeachnumberedboxareenumeratedbelow:
BOX1

BOX2
BOX3
BOX4

BOX5
BOX6

BOX7

BOX8

BOX9

BOX10

MSB

MonthlySalaryRange

SalaryBase(SB)

TotalMonthly
Contribution

PersonalShare EmployerShare
(PS)
(ES)

WritethecompletePHILHEALTHNUMBERandEMPLOYERTINinthecorrespondingboxes.IfwithoutPEN,employersmayregisterwiththePhilippineBusiness
Registry(PBR)andtheCorporationshallnolongerrequiresubmissionofdocuments.However,shouldtheemployerbeunabletoregisterthroughthePBR,itshall
berequiredtoattachadulyaccomplishedER1formandanyofthefollowingdocuments,whicheverisapplicable:
a.ForsingleproprietorshipsDepartmentofTradeandIndustry(DTI)registration;
b.ForpartnershipsandcorporationsSecuritiesandExchangeCommission(SEC)registration;
c.ForfoundationsandothernonprofitorganizationsSECregistration;
d.ForcooperativesCooperativeDevelopmentAuthority(CDA)registration;
e.Forbackyardindustries/venturesandmicrobusinessenterprisesBarangayCertificationand/orMayorsPermit.

8,999.99andbelow

8,000.00

200.00

100.00

9,000.00to9,999.99

9,000.00

225.00

112.50

112.50

10,000.00to10,999.99

10,000.00

250.00

125.00

125.00

11,000.00to11,999.99

11,000.00

275.00

137.50

137.50

12,000.00to12,999.99

12,000.00

300.00

150.00

150.00

13,000.00to13,999.99

13,000.00

325.00

162.50

162.50

WritetheCOMPLETEEmployerName,MailingAddress,TelephoneNumberandEmailAddress(DONOTABBREVIATE).
CheckapplicableboxfortheEMPLOYERTYPE.

14,000.00to14,999.99

14,000.00

350.00

175.00

175.00

15,000.00to15,999.99

15,000.00

375.00

187.50

187.50

16,000.00to16,999.99

16,000.00

400.00

200.00

200.00

10

17,000.00to17,999.99

17,000.00

425.00

212.50

212.50

11

18,000.00to18,999.99

18,000.00

450.00

225.00

225.00

12

19,000.00to19,999.99

19,000.00

475.00

237.50

237.50

13

20,000.00to20,999.99

20,000.00

500.00

250.00

250.00

14

21,000.00to21,999.99

21,000.00

525.00

262.50

262.50

15

22,000.00to22,999.99

22,000.00

550.00

275.00

275.00

16

23,000.00to23,999.99

23,000.00

575.00

287.50

287.50

17

24,000.00to24,999.99

24,000.00

600.00

300.00

300.00

18

25,000.00to25,999.99

25,000.00

625.00

312.50

312.50

19

26,000.00to26,999.99

26,000.00

650.00

325.00

325.00

20

27,000.00to27,999.99

27,000.00

675.00

337.50

337.50

21

28,000.00to28,999.99

28,000.00

700.00

350.00

350.00

22

29,000.00to29,999.99

29,000.00

725.00

362.50

362.50

23

30,000.00To30,999.99

30,000.00

750.00

375.00

375.00

24

31,000.00to31,999.99

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 RF1 form and check the box
correspondingtoAdditiontoPreviousRF1orDeductiontoPreviousRF1,whicheverisapplicable.Writeonlythenamesoftheemployeeswitherroneous
contributionsandthedifferencebetweenthecorrectamountandtheamountthatwaspreviouslyreported.Ifanunderpaymentresultsduetocorrection,please
remit the amount due to PhilHealth. Use separate/different sets of RF1 form for each month when reporting previous payments or late payments made on
previousmonth(s).
Alwaysindicatetheapplicablemonthandyearofpremiumcontributionspaid.ThemonthandyearcoverageintheRF1shouldcorrespondwiththemonthand
yearcoverageindicatedinthePAR/POR/TransactionReferenceNumber.
IndicatethecorrespondingPHILHEALTHIDENTIFICATIONNUMBER(PIN)oppositetherespectivenamesofyouremployees.Forinitialregistrationorupdatingof
memberdatarecordand/ordeclarationofdependents,requiretheemployee/stoproperlyaccomplishthePhilHealthMemberRegistrationForm(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
updatingofthemembershipdatarecordofsuchemployee/s.
PrintnamesofEmployeesinalphabeticalorder.WritethecompletenameofeachemployeebyprovidingtheLastName,FirstName,NameExtension(Sr.,Jr.,
orII,III,iftherebeany)andMiddleName(LeaveBlankforemployeewithoutMiddleName).Donotskiplineswhenlistingdowntheirnames.WriteNOTHING
FOLLOWSonthelineimmediatelyfollowingthelastlistedemployee.
Incasethattheemployee/slistedinthesubmittedRF1hasnotyetbeenissuedhis/herpermanentPIN,indicatehis/herDATEOFBIRTHandSEXinthecolumn
providedtofacilitatetheimmediateassignmentandgenerationofPIN.Otherwise,leavethecolumnblankandensurethatthePIN/sinboxno.6is/arecorrectly
indicated.

100.00

Indicate the employees respective MONTHLY SALARY BRACKET (MSB) corresponding to the MONTHLY SALARY RANGE where the employees monthly salary
falls.PleaserefertotheNHIPMONTHLYPREMIUMCONTRIBUTIONSCHEDULEontherightforyourreference.CorrespondingMSBnotfilledoutshallmeanthat
suchemployeescompensationfortheparticularperiodshallbelongtothehighestbracket.

25

32,000.00to32,999.99

32,000.00

800.00

400.00

400.00

26

33,000.00to33,999.99

33,000.00

825.00

412.50

412.50

IndicatethecorrespondingPERSONALSHARE(PS)andEMPLOYERSHARE(ES)ontheboxesprovidedforeachremittance.TheTotalPremiumContribution(PS+
ES)forthemonthmustfallwithintheprescribedbracket.

27

34,000.00to34,999.99

34,000.00

850.00

425.00

425.00

28

35,000.00andup

35,000.00

875.00

437.50

437.50

BOX11 IntheEMPLOYEESTATUScolumnindicatetheletterSiftheemployeeisSeparated, NEifwithNoEarningsandNHifemployeeisNewly Hired.

NHIPMONTHLYPREMIUMCONTRIBUTIONSCHEDULEFOR2014

Supply needed informationon the ACKNOWLEDGEMENTRECEIPT (PAR/POR/Transaction ReferenceNumber) boxes. Indicate in the corresponding boxthe
ApplicablePeriod,RemittedAmount,AcknowledgementReceiptNumber,TransactionDateandNumberofEmployees.

BOX14

AddallcontributioninthePERSONALSHARE(PS)columnandEMPLOYERSHARE(ES)columnfortheapplicablemonthandreflectthesumintheSUBTOTALbox
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
accomplishedRF1toindicatetotalamountofcontributionspaidforthesaidapplicablemonth.

BOX15

Affixsignatureovercompleteprintednameoftheauthorizedofficerpreparingthereport,his/herofficialdesignationanddate.

BOX16

Affixsignatureovercompleteprintednameoftheauthorizedofficercertifyingthereport,his/herdesignationanddate.

BOX17

Alwaysindicatecorrectpagenumberandthetotalnumberofpagesforeachform.

COPYDISTRIBUTION
Form
RF1
PAR

No.ofCopies
2
4

1st
PHIC
PAYOR

2nd
PAYOR
COLLECTINGAGENTS
COPY

3rd
X
PHIC

REMINDERS:

4th
X
PHIC

SubmitoriginalcopyofthisdulyaccomplishedformwiththecorrespondingcopiesofthevalidatedPAR/POR/Transaction
Reference Number to the Collection Section/Unit of the respective PhilHealth Regional or Local Health Insurance Office
withinfive(5)daysafterpayment.Thescheduleforthepaymentofcontributionsisonthe11thto15thdayforemployers
with PENs ending in 04; and16th to 20th day for employers with PENs ending in 59following 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
concernedemployeeordependent/savailsofProgrambenefits,withoutprejudicetotheimpositionofotherpenalties.

THISFORMMAYBEREPRODUCEDANDISNOTFORSALE