Remittance Form as Proof of Overseas Premium Payments
Remittance Form as Proof of Overseas Premium Payments
Remittance Form as Proof of Overseas Premium Payments
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@i^<br />
Republic <strong>of</strong> the Philippinesi'/J/J*-<br />
PHILIPPINE HEALTH INSURANCE CORPORATION|/' ,i<br />
Oityslate Centre, 709 Shaw Boulevard, P<strong>as</strong>ig City,#5
"Annex A"<br />
DBP Hong Kong<br />
DBP REMITTANCE CENTRE HK LTD<br />
Shop 214. 2/F World Wide Plaza<br />
19 Des Voeux Road. Central, Hong Kong<br />
Tel # (852) 2530-9138. (852) 2537-470B<br />
Client Copy<br />
PHILHEALTH CONTRIBUTION<br />
OFFICIAL RECEIPT<br />
NO.<br />
PHP Amount<br />
Exch Rale<br />
HKD Equivalent<br />
TOTAL DUE IN HKD<br />
TENDER<br />
CHANGE<br />
SENDER'S SIGNATURE<br />
Payingmembershallfill-outDBP<strong>Remittance</strong>CentreHK,Ltd.<strong>Remittance</strong>/Payment<br />
formwiththefollowinginformation:<br />
No<br />
l<br />
2<br />
3<br />
<strong>Form</strong>Field<br />
SENDERDETAILS<br />
(Name,AddressandTel<br />
No)<br />
BENIFICIARYDETAILS<br />
(Name,Address,ZIP<br />
Code,andTelNo)<br />
Date<br />
RequiredDetails<br />
Name,Current/foreignaddress,andContactnumber<strong>of</strong>payor<br />
Member'sname,Philippineaddress,ZIPCode,andcontact<br />
number<br />
Dateandtime<strong>of</strong>transaction<br />
A<br />
PhpAmount<br />
Theamountpaid.
DBP Tie-up (Enjaz)<br />
"Annex B"<br />
Payingmembershallfill-outtheEnjazBankingServices<strong>Remittance</strong>/Paymentform<br />
withthefollowinginformation:<br />
No<br />
<strong>Form</strong>Field<br />
RequiredDetails<br />
1<br />
2<br />
3<br />
4<br />
5<br />
6<br />
7<br />
8<br />
9<br />
DATE<br />
THESUM<br />
CORRESPBANK<br />
BENEF'SNAME<br />
BENEF'SA/CNO.<br />
BENEF'SBANK<br />
REMITTER'SNAME<br />
IDTYPE<br />
IDNO.<br />
NATIONALITY<br />
Date<strong>of</strong>transaction<br />
Theamountpaid<br />
Name<strong>of</strong>PhilHealthAccreditedCollectingAgency(ACA)inthe<br />
Philippinesaffiliatedwiththebank.<br />
Name<strong>of</strong>Member<br />
Member'sPhilHealthIdentificationNumber(PIN)<br />
Thename<strong>of</strong>serviceagency(PhilHealth)thatwillreceivethe<br />
payment<br />
Name<strong>of</strong>payee<br />
IdentificationDevicetypeandnumber<br />
Nationality<strong>of</strong>member
p.<br />
PVB Tie-up<br />
"Annex C"<br />
A BTI MONEY TRANSFER PTE. LTD. @s,saNo@lrece,p<br />
3M ORCHARD ROAD 103-GSI81 LUCKV PLAZA SINGAPORE 238863<br />
TEL: 67330103 FAX-67374539<br />
LICENSED REMITTANCE CENTRE<br />
kREG. NO.: 2006127161.1<br />
I CUSTOMER HO :<br />
2-j@5f ??/ic 1:0<br />
3-j^ ADDRESS<br />
4-;@> rv.L<br />
I I, BENEFICIARY<br />
DATE/VIMt;@<br />
r\ECEHJT HO:<br />
MODE <<br />
A/C i;O :<br />
AMOUNT TO BEs<br />
REMITTED:<br />
EXCHANCK RftTE:<br />
SS E2L':VA1EH-;-:<br />
SERVICE KE:<br />
M!SC TEE:<br />
TOTAL:<br />
n<br />
r-MKEKT RECEIVED 3Y|<br />
SERVICE CHARGE IS NOT REFUNDABLE.<br />
CWEI1SEAS AGENT BTI COUaiER EXPRESS INC.<br />
Payingmembershallfill-outtheBTIMoneyTransferPTE,Ltd.<br />
<strong>Remittance</strong>/Paymentformwiththefollowinginformation:<br />
No<br />
<strong>Form</strong>Field<br />
RequiredDetails<br />
l<br />
2<br />
SENDER<br />
PP/1CN0.<br />
Name<strong>of</strong>payor<br />
P<strong>as</strong>sportorIdentification/IdentityCardnumber<br />
andnationality<strong>of</strong>member<br />
3<br />
ADDRESS<br />
Current/foreignaddress<strong>of</strong>payor<br />
4<br />
TEL<br />
Contactnumber<strong>of</strong>payor<br />
5<br />
BENIFICIARYDETAILS<br />
(BENEFICIARY,OR,<br />
ADDRESSANDTEL)_<br />
Member'snameorname<strong>of</strong>arepresentative,<br />
Philippineaddressandcontactnumber<br />
6<br />
DATE/TIME<br />
Dateandtime<strong>of</strong>transaction<br />
7<br />
8<br />
MODE<br />
AMOUNTTOBE<br />
REMITTED<br />
Thename<strong>of</strong>serviceagency(PhilHealth)thatwill<br />
receivethepayment<br />
Theamountpaid.
"Annex D"<br />
I-Remit<br />
Singapore pte ltd<br />
REMITTANCE APPLICATION fORE.T '<br />
OPPlCliVL P.EChlPJ<br />
Payingmembershallfill-outtheEnjazBankingServices<strong>Remittance</strong>/Paymentform<br />
withthefollowinginformation:<br />
No<br />
<strong>Form</strong>Field<br />
RequiredDetails<br />
1<br />
2<br />
No.<br />
PayAmount<br />
Name,address,permanentaddressandcontactnumber<strong>of</strong>payor<br />
Theamountpaid<br />
3<br />
LocalTransDate<br />
Date<strong>of</strong>transaction<br />
4<br />
5<br />
6<br />
7<br />
DeliveryMode<br />
Beneficiary,BirthDate,<br />
Address<br />
ServiceCenter<br />
AccountNo.<br />
Theidentificationdeviceprovidedbythepayortoverifythe<br />
identity<strong>of</strong>thebeneficiary<br />
Name,birthdateandaddress<strong>of</strong>Member<br />
Thename<strong>of</strong>serviceagency(PhilHealth)thatwillreceivethe<br />
payment<br />
Member'sPhilHealthIdentificationNumber(PIN}
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