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Cocolife Application Form PDF

The document appears to be an application form for health maintenance organization (HMO) coverage through COCOLIFE HEALTHCARE. It requests personal information from the applicant such as name, address, birthdate, employment details, and lists of dependents to be covered. The form also includes tables outlining the coverage options and fees, including maximum annual benefits, monthly and annual premiums based on the level of coverage (open private, semi-private, etc.) and family size. It provides details on eligibility, qualified dependents, pre-existing conditions, network access, additional benefits and notes on premium rates.

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Jocelyn M. Faner
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2K views2 pages

Cocolife Application Form PDF

The document appears to be an application form for health maintenance organization (HMO) coverage through COCOLIFE HEALTHCARE. It requests personal information from the applicant such as name, address, birthdate, employment details, and lists of dependents to be covered. The form also includes tables outlining the coverage options and fees, including maximum annual benefits, monthly and annual premiums based on the level of coverage (open private, semi-private, etc.) and family size. It provides details on eligibility, qualified dependents, pre-existing conditions, network access, additional benefits and notes on premium rates.

Uploaded by

Jocelyn M. Faner
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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REGION: ______________________

APPLICATION FORM NO: _________


DATE: ________________________
HMO APPLICATION FORM
FAMILY NAME: FIRST NAME: MIDDLE NAME

ADDRESS (HOME):

DATE OF BIRTH: PLACE OF BIRTH: SEX: MALE CIVIL STATUS: MARRIED WIDOWED
FEMALE SINGLE DIVORCED SEPARATED
PLACE OF ASSIGNEMENT: DIVISION/SECTION: POSITION: CONTACT NO:

IS YOUR SPOUSE A DAR EMPLOYEE? YES NO


IF YES, PLACE OF ASSIGNMENT _____________ POSITION __________
DEPENDENTS: CATEGORY
FAMILY NAME FIRST NAME M.I. BIRTH DATE RELATIONSHIP PLAN (Open Private)
TO EMPLOYEE (MBL P130,000.00)
_____________ _____________ ____ ___________ ____________  Employee Only
_____________ _____________ ____ ___________ ____________  Family of 3

_____________ _____________ ____ ___________ ____________


 Family of 5
 Family of 7
_____________ _____________ ____ ___________ ____________
 Family of 9
_____________ _____________ ____ ___________ ____________
PLAN (Semi Private Open)
_____________ _____________ ____ ___________ ____________ (MBL P90,000.00)
_____________ _____________ ____ ___________ ____________  Employee Only
_____________ _____________ ____ ___________ ____________  Family of 3
_____________ _____________ ____ ___________ ____________  Family of 5
 Family of 7
_____________ _____________ ____ ___________ ____________
 Family of 9
EXTENDED FAMILY MEMBER/S:
FAMILY NAME FIRST NAME M.I. BIRTH DATE RELATIONSHIP CATEGORY
TO EMPLOYEE
_____________ _____________ ____ ___________ ____________  PLAN (Open Private)
_____________ _____________ ____ ___________ ____________ (MBL P130,000.00)

_____________ _____________ ____ ___________ ____________  PLAN (Semi Private Open)


_____________ _____________ ____ ___________ ____________ (MBL P90,000.00)
_____________ _____________ ____ ___________ ____________
IRREVOCABLE AUTHORIZATION FOR DEDUCTION OF PAYMENT
I hereby authorize the Cashier of the ______________________ to deduct from my monthly salary, the amount
of ________________ (PHP _____.__) for a period of twelve (12) months starting December 2019 representing my
personal premium contribution to the said plan. However, in the event that I resign or be separated from employment,
before completing my payment, I therefore authorize the cashier to deduct my entire obligation from my
retirement/separation and other benefits that may due to me. Further, in case of voluntary withdrawal from the
program, anytime during the inclusive year of coverage, I also undertake to pay the whole premium amount in cash.
I hereby declare that the foregoing statements are true and correct to the best of my knowledge and ability. As
a new enrollee, I hereby submit my and my dependents’ medical records for evaluation purposes regarding my
application to the COCOLIFE HEALTHCARE.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of _____ 20__ in_____________,
Philippines.

______________________________________
(Signature over printed name of applicant)
ANNUAL SUBSCRIPTION OF FEES
FOR CY 2020

ACCOMMODATION MAXIMUM COVERAGE MONTHLY FEES ANNUAL FEES


BENEFIT PER YEAR (12 MONTHS)
OPTION I – FAMILY PACKAGE
OPEN PRIVATE
FAMILY OF 3 PHP 130,000.00 PHP 2,474.00 PHP 29,688.00
FAMILY OF 5 PHP 130,000.00 PHP 2,887.00 PHP 34,644.00
FAMILY OF 7 PHP 130,000.00 PHP 3,345.00 PHP 40,140.00
FAMILY OF 9 PHP 130,000.00 PHP 3,711.00 PHP 44,532.00
SEMI PRIVATEOPEN
FAMILY OF 3 PHP 90,000.00 PHP 1,813.00 PHP 21,756.00
FAMILY OF 5 PHP 90,000.00 PHP 2,116.00 PHP 25,392.00
FAMILY OF 7 PHP 90,000.00 PHP 2,452.00 PHP 29,424.00
FAMILY OF 9 PHP 90,000.00 PHP 2,720.00 PHP 32,640.00
OPTION II – INDIVIDUAL / EMPLOYEES ONLY
OPEN PRIVATE PHP 130,000.00 PHP 2268.00 PHP 27,216.00
SEMI PRIVATE OPEN PHP 90,000.00 PHP 1511.00 PHP 18,132.00
OPTION III – EXTENDED FAMILY PER DEPENDENTS
OPEN PRIVATE PHP 120,000.00 PHP (UPON REQUEST) PHP (UPON REQUEST)
SEMI PRIVATE OPEN PHP 80,000.00 PHP (UPON REQUEST) PHP (UPON REQUEST)

ELIGIBILITY
Principal Member - All employees of the company who are up to 65 years old are eligible for membership.

QUALIFIED DEPENDENTS:
For Single Employees:
 Parents – not more than 65 years’ old.
 Brothers/Sisters at least 90 days old but below 21 years old, single and unemployed.
 Children of single parents at least 90 days old but below 21 years old, single and unemployed.
For Married Employees:
 The legal spouse up to 65 years’ old.
 Children of parents at least 90 days old but below 21 years old, single and unemployed.
For Extended Dependents:
 Parents up to 65 years of age for married employees.
 Children of single or married employees who are 21 years old and above.
 Brothers and sisters who are 21 years old and above of married employees.
 Siblings of single employees who are 21 years old and above.

NOTE: Hierarchy Rule is strictly observed.


Additional Dependents shall not be enrolled not later than one (1) month after enrollment of the principal member.

Special Accommodation for EXISTING OVERAGE members:


 66-70 years old – twice the premium.
 71-75 years old – thrice the premium.
Pre Existing Covered: Up to AggBL/MBL.
Network Access: a) Without access to all Healthway Medical Clinics, SLMC Globa, and Asian Hospital and Medical Center.
b) Semi-private – Without access to St. Luke’s Medical Center – QC, The Medical City, Makati Med and Cardinal
c) Open Private – With access to The Medical City, St. Luke’s Medical Center – QC, Makati Med and Cardinal.
Standard Dental thru Cocolife Dental Network.
Financial Assistance to employees: a) Natural Death – PHP50,000
b) Accidental Death – PHP50,000
Others: a) Philhealth Integrated Program.
b) Rates are applicable for 1,000 principal enrollees of the whole DAR employees/various chapters, any reduction by
more than 5% shall mean re-evaluation of membership fees.

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