Redesign1 2024 Mutual Aid System Form

NMAS Application Form

New Mutual Aid System
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.
QUALIFICATIONS:

1. Applicant must be “PERMANENT in service;
2. DepEd Employee (Teaching or Non-Teaching);
3. Capacity to pay;
4. Not more than 60 years old for NMAS applicant

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.
Know More: Products and Services Information
DOCUMENTARY REQUIREMENTS:

1. SCANNED COPY (CLEAR SHOT) OF LATEST PAYSLIP;
2. SCANNED COPY (CLEAR SHOT) OF PERMANENT APPOINTMENT or SERVICE RECORD;
3. SCANNED COPY (CLEAR SHOT) OF TWO (2) VALID IDs or DULY VERIFIED PHILID/ePhilID (NATIONAL ID)
4. CLEAR SHOT OF RECENT ID PICTURE
5. PHILIPPINE NATIONAL PUBLIC KEY INFRASTRUCTURE (PNPKI) DIGITAL SIGNATURE ISSUED BY DepEd;
6. DIGITALLY SIGNED (using PNPKI) ACCOMPLISHED APPLICATION FORM/S PRINTED ON A LEGAL (LONG) SIZE BOND PAPER ( 8.5 X 14 inches )

Once you’ve gathered the documentary requirements and filled out the form, you’re ready for the next steps of the application process
Date

MonthDayYear
Date
PERSONAL INFORMATION
currentDate

MonthDayYear
Date
Family Name*
First Name*
Middle Name*
Date of Birth*

MonthDayYear
Date
Age
Civil Status*
Gender*
Mobile No*
Landline No.
DepEd Email Address*

Confirmation Emailjuandelacruz@deped.gov.ph
Region*
Division*
Station*
Employee number*
House no. Street Name Barangay*
Municipality/City*
Province*
Zip Code*
Name of School*
School Address*
Number, street, Barangay
School Address
Municipality/City, Province
Status of Employment*

PermanentProvisional
Payment*

Regional Payroll System UnitDirectLocal(H. School/College/University)
Mode of Payment*

MonthlyQuarterlyAnnually
BENEFICIARIES - Provide additional sheet/s if necessary- must be certified correct and signed by the member himself/herself) ()Surname,Middle Name)Date of Birth(mm-dd-yyy
Beneficiary 1
Name
Date of Birth

MonthDayYear
Relation
Share %
check if irrevocable

irrevocable
Check to Add More Beneficiary

Add Beneficiary 2Add Beneficiary 3Add Beneficiary 4Add More Beneficiary
Beneficiary 2
Name
Date of Birth

MonthDayYear
Relation
Share %
check if irrevocable

irrevocable
Beneficiary 3
Name
Date of Birth

MonthDayYear
Date
Relation
Share %
check if irrevocable

irrevocable
Beneficiary 4
Name
Date of Birth

MonthDayYear
Date
Relation
Share %
check if irrevocable

irrevocable

Add Solicitor's Name

Yes
SOLICITOR'S NAME
Input the Name of Solicitor
HEALTH DECLARATION, CERTIFICATION, VENUE OF ACTION AND RECOMMENDATION
1. Are you in good health and free from physical impairment, any deformity or disease?*

YESNO
2. During the last five (5) years, have you been hospitalized, or consulted or been treated by a physician for any reason?*

YESNO
3. Have you been treated for or been advised that you had any of the following: Heart, Lungs, Nervous or Kidney Disorder, High Blood Pressure, Cancer, Tumor or Diabetes?*

YESNO
I hereby certify that the above information are true and correct. I further cerfity that I have read and understand all rules and regulations pertaining to the New Mutual Aid System (NMAS) , and I abide fully by the terms of the same without any reservation. I hereby agree that all actions relating therewith shall be brought exclusively before the Regional Trial Court of Quezon City.
Customary Signature over Printed Name of Applicant (make sure to click the upload button after you select picture)
Two speciment signature of Applicant: (make sure to click the upload button after you select picture)
Two speciment signature of Applicant: (make sure to click the upload button after you select picture)
Date

MonthDayYear
Date
REQUIREMENTS

Photocopy of Latest PayslipPermanent Appointment/ Latest Service RecordPhotocopy of at least two (2) valid ID's
HEALTH DECLARATION
Name
Age
Position / Division / Office
Amount of Insurance Plan
Date of Birth

MonthDayYear
Date
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, Kidney Diseases, Urinary Tract Diseases

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

YESNO
d. Cancer or tumor?

YESNO
E. Mental illness?

YESNO
f. Disease of the stomach, liver, gallbladder,intestines, or any 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
I. 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
b. To the best of your knowledge and belief, are you now pregnant?

YESNO
Done at
This
Day of
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
Peso in Number
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 / 004C. 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.
Beginning On

MonthDayYear
Date
Ending On

MonthDayYear
Date
Employee No
Station Code
Division Code
Region
Date

MonthDayYear
Date
Recommending Officer
Approving Officer
Date

MonthDayYear
Date
Click select image to ATTACH and UPLOAD your recent ID picture
• 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 *

Upload File

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2. Permanent Appointment/ Latest Service Record*

Upload File

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3. Photocopy of at least two (2) valid ID's*

Upload File

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4. Final Application Form in PDF Duly-signed Using PNPKI*

Upload File

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5. Selfie Photo While Holding the Duly-Accomplished Membership Application Form

Upload File
(make sure to click the upload button after you select picture) Cancelof
After Uploading All the files click the Submit Button
Should be Empty:

	Name	Date of Birth	Relation	Share
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NMAS Application Form

PERSONAL INFORMATION

HEALTH DECLARATION, CERTIFICATION, VENUE OF ACTION AND RECOMMENDATION

HEALTH DECLARATION

THROUGH THE DEPED AUTOMATIC PAYROLL DEDUCTION SYSTEM (APDS)