Redesign2023 MRBS Plus

MRBS Plus APPLICATION FORM

Mutual Retirement Benefit System Plus
CONSENT STATEMENT

By supplying your personal and sensitive information with the Philippine Public School Teachers Association (hereinafter referred as “PPSTA“ or the “company”) in this digital platform in the process of applying for and/or availing of insurance plans, loans, benefit claims and engaging the company for any other business transaction in accordance to its legitimate purpose as a mutual benefit association, you hereby consent to the processing, sharing, and/or transferring of your personal data relating to your account/s to PPSTA, its service providers or third parties/entities having authority or right and need to such disclosure of information including regulatory agencies, governmental or otherwise, in order to enable the company to service your account/s and needs, to provide all existing features and future enhancements thereto, and to avail other products, services, facilities, and channels available to you as member of the association. You likewise agree to hold PPSTA, and third party service providers free and harmless from any liability arising from or in connection with the consent herein given.

This consent statement is in compliance to the Data Privacy Act of 2012 and its implementing rules and regulations. For further clarification and guidelines of your Privacy Rights, you may refer to the our PPSTA Privacy Policy.
Terms and Conditions*
QUALIFICATIONS:

1. Applicant must be “PERMANENT in service;
2. DepEd Employee (Teaching or Non-Teaching);
3. Capacity to pay;
4. Not more than 54 years old for MRBS PLUS applicant

Once you’ve gathered the documentary requirements and filled out the form/s, you’re ready for the next steps of the application process
Products and Services Information
REQUIREMENTS

1. Personal Health Declaration form/ Latest Medical Certificate
2. Photocopy of Latest Payslip
3. Permanent Appointment/ Latest Service Record
4. Photocopy of at least two (2) valid ID's

Click the button below and upload all files

Please supply all information indicated below and requirements submitted shall be the basis of approval or disapproval of your application, subject to the terms and conditions of NMAS printed at the back of your accomplished application.
Last Name*
First Name*
Middle Name*
Date of Birth*

MonthDayYear
Date
Age*
Civil Status*
Gender*
Mobile No*
Landline No
DepEd Email Address*
example@example.com
Region*
Division*
Station*
Employee Number*
Zipcode*
Home Address*
Number, street, Barangay
Municipality/City, Province
Name of School*
School Address*
Number, street, Barangay
Municipality/City, Province
Hospitalization benefits / 30 days per year in any sickness except pregnancy.
Plan Applied for*

PLAN 50 (50,000.00) - ₱ 500 per dayPLAN 75 (75,000.00) - ₱ 750 per dayPLAN 100 (100,000.00) - ₱ 1,000 per day
Date of Application*

MonthDayYear
Date
Beneficiaries
1. Beneficiary
1. Birth Date

MonthDayYear
Date
1. Relation
1. Share %
(if equal sharing just type equal share)
Check to Add More Beneficiary

Add Beneficiary 2Add Beneficiary 3Add Beneficiary 4Add Beneficiary 5
2. Beneficiary Name
2. Birth Date

MonthDayYear
Date
2. Relation
2. Share %
(if equal sharing just type equal share)
3. Beneficiary Name
3. Birth Date

MonthDayYear
Date
3. Relation
3. Share %
(if equal sharing just type equal share)
4. Beneficiary Name
4. Birth Date

MonthDayYear
Date
4. Relation
4. Share %
(if equal sharing just type equal share)
5. Beneficiary Name
5. Birth Date

MonthDayYear
Date
5. Relation
5. Share %
(if equal sharing just type equal share)
Customary Signature over Printed Name of Applicant (make sure to click the upload button after you select picture)
Date*

MonthDayYear
Date
REQUIREMENTS

Personal Health Declaration form/Latest Medical CertificatePermanent Appointment/Latest Service RecordPhotocopy of Latest PayslipPhotocopy of at least two (2) valid IDs
Add Solicitor's Honorarium

Enable
Solicitor's Name
Health Declaration
Proposed Insured
1. Ever applied for or received disability benefit or pension? If so why?*

YESNO
2. Ever consulted or been treated by any Physician or other Medical practitioner for any disease pertaining to:*

YESNO
a. Chest pains, high blood pressure or heart disease?*

YESNO
b. Diabetes, disease of kidney, ureters and urinary bladder?*

YESNO
c. Tubercolosis, asthma, or lung disease?*

YESNO
d. Cancer or tumor?

YESNO
e. Nervous or Mental illness?

YESNO
f. Disease of the stomach, liver, gallbladder,intestines, or other abdominal organs?*

YESNO
g. Any other disease not mentioned?*

YESNO
h. Surgical operation, Medical consultation or treatment?*

YESNO
i. X-ray, ECG, urine, blood, or other special tests or examinations?*

YESNO
j. Do you have any defect or deformity*

YESNO
k. Ever used alcoholic beverages to excess, taken habit forming drugs or sought advice or treatment for alcoholism drug habit or other addiction?*

YESNO
l. Any medical attention other than those mentioned above?*

YESNO
3. Lost weight in the last 12 months? If so, how many pounds?*

YESNO
4. a. Have you ever had any disorder of menstruation, pregnancy , of the female organ or breast?

YESNO
4. b. To the best of your knowledge and belief, are you now pregnant?

YESNO
Present weight in pounds?
Present height in feet and inches?
Done at
Place
This
Month
Day of
Year 20
THROUGH THE DEPED AUTOMATIC PAYROLL DEDUCTION SYSTEM (APDS)
I hereby authorize DepEd to deduct monthly from my salary, through the DepEd APDS, the sum of PESOS: beginning on and ending on

) as premium/contribution, and to remit the same to Philippine Public School Teachers Association (PPSTA)in

consideration of the insurance policy/membership/other allowed obligation, more specifically described as 0044A. In case my premium contribution is not deducted from the payroll, regardless of the reason, I also authorize DepEd to automatically adjust the termination period in my pay slip by one (1) month for every month of delay of its deduction. I fully understand that no lapses of payment shall be made by the Accredited Entity for this purpose, thus, the corresponding benefit as contracted shall be available in case of need.

The authorization is VALID AND BINDING within the aforementioned period., unless the authorization is otherwise revoked. Morever, I agree that deductions that will reduce my monthly net take-home pay to lower than what is allowed under the law shall not be accommodated in the APDS.
APDS, the sum of PESOS
Amount in Numbers
Beginning On

MonthDayYear
Date
Ending On

MonthDayYear
Date
Region
Upload Photo (1x1 picture)

(make sure to click the upload button after you select photo)
• Please click “Preview and Download PDF” button below to download the encoded application form.
• Open the Application form in any PDF Editor(Adobe Acrobat, NitroPDF etc)
• Attach your PNPKI Digital Signature(Click here to know how)
• Save Changes Made and Print hard copy
• Upload the Accomplished Application Form and Selfie Photo(holding the printed form)
UPLOAD these Requirements

1. Photocopy of Latest Payslip
2. Permanent Appointment/ Latest Service Record
3. Photocopy of at least two (2) valid ID's
4. Final Application Form in PDF Duly-signed Using PNPKI
5. Selfie Photo While Holding the Duly-Accomplished MRBS Plus Application Form

Click the Upload File button
Upload File

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Upload File Requirements

Browse Files
(make sure to click the upload button after you select picture) Cancelof
Should be Empty:

MRBS Plus APPLICATION FORM

Hospitalization benefits / 30 days per year in any sickness except pregnancy.

Beneficiaries

Health Declaration

THROUGH THE DEPED AUTOMATIC PAYROLL DEDUCTION SYSTEM (APDS)