CLIENT INFORMATION SH
to be filled out by the Corpora
COMPANY NAME
:
(AS REFLECTED IN SEC/DTI REGISTRATION)
COMPANY ADDRESS :
AUTHORIZED SIGNATORY
to appear in the Health Care Agreement :
(HCA)
DESIGNATION :
CONTACT PERSON :
DESIGNATION :
BILL ADDRESSEE :
DESIGNATION :
TELEPHONE NUMBER :
NATURE OF BUSINESS :
EMAIL ADDRESS :
COMPANY TIN :
PREFERRED EFFECTIVE DATE :
MODE OF PAYMENT : ANNUAL SEMI-ANNUAL
NUMBER OF ENROLLEES : PRINCIPALS
OPEN ACCESS INCL. TOP 6
PROGRAM TYPE :
LUZON ONLY (EXCEPT NCR)
CHOSEN PLAN TYPE
EMPLOYEE CATEGORY MEMBER TYPE ACCOMMODATION
MATION SHEET (CIS)
d out by the Corporate Client
SEMI-ANNUAL QUARTERLY
DEPENDENTS
OPEN ACCESS EXCL. TOP 6
VISMIN ONLY
YPE
MEMBERSHIP FEE
MBL (BASED ON HEADCOUNT
PROPOSAL)
Legend:
IF NECESSARY
REQUIRED
Note: See other column guides below
PRINCIPALS
NO. MEMBER TYPE MEMBER CLASSIFICATION (P or D) EMPLOYEE
NUMBER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
↑ ↑ ↑
P - PRINCIPAL P - PRINCIPAL / EMPLOYEE COMPANY
S - SPOUSE D - DEPENDENTS EMPLOYEE
C - CHILD NO.
A - PARENT
B - SIBLING
IF NECESSARY
REQUIRED
NOTE: Column AE (auto-compute) for validation of over-age and wrong encoding.
FOR STANDARD DEPENDENT’S COVERAGE (following hierarchy guidelines)
- Single employees
/s first who is/are less than 65 years old and not gainfully employed; followed by the eldest sibling down to the
- Single Parent employees
Principal should enroll the eldest child down to the youngest, 15 days to less than 21 years
- Married employees
should enroll their spouse first who is less than 65 years old, followed by the eldest child down to the youngest
Note: If they are currently covered by another HMO, kindly furnish us immediately a photocopy of their
FOR DIFFERENT SURNAME FROM THE PRINCIPAL'S
- Spouse Dependent
Provide Marriage Certificate (Photocopy)
- Child(ren) / Sibling(s) Dependent(s) / Parent Dependent(s)
Provide Birth Certificate
PREMIUM CLASS/
BENEFIT CLASS MBL REMARKS LAST NAME
MEMBERSHIP FEE
EX. ↑ ↑
SUITE PREMIUM FEES
PRIVATE
SEMI-PRIVATE
WARD
ng down to the youngest, who is/are 15 days to less than 21 years old, unmarried and not gainfully employed.
ss than 21 years old, unmarried and not gainfully employed.
to the youngest, 15 days to less than 21 years old, unmarried and not gainfully employed.
otocopy of their current membership card with the date of expiration / Certificate of Health Insurance with valid
e (Photocopy)
ficate
MIDDLE DATE OF BIRTH
FIRST NAME SUFFIX GENDER
NAME (MM/DD/YYYY)
↑ ↑
MONTH IN WORD DAY Y M
F
ly employed.
ance with validity date.
CIVIL STATUS (S - SINGLE;
M - MARRIED; P - SINGLE
PARENT; W - HOME
ADDRESS MOBILE E-MAIL
WIDOW/WIDOWER; SE - PHONE
SEPARATED; A -
ANNULLED)
↑
S - SINGLE
M - MARRIED
P - SINGLE PARENT
W - WIDOW/WIDOWER
SE - SEPARATED
A - ANNULLED
PHILHEALTH SUB-GROUP
OFFICE OFFICE DATE HIRED
SSS NUMBER TIN MEMBER (COMPANY
PHONE FAX (MM/DD/YYYY)
(Y/N) AFFILIATION)
↑
MM/DD/YYYY
POSITION RELATIONSHIP TO PRINCIPAL
↑
EXECUTIVE
MANAGER
SUPERVISOR
RANK AND FILE
PRINCIPAL LAST NAME (REQUIRED IF ROW IS PRINCIPAL FIRST NAME (REQUIRED IF ROW IS
DEPENDENT) DEPENDENT)
PREMIUM
PRINCIPAL BIRTH DATE
EFFECTIVIT EXPIRY VIP CLASS/
(REQUIRED IF ROW IS AGE
Y DATE DATE TAGGING MEMBERSHIP
DEPENDENT)
FEE
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
↑ ↑ ↑ ↑
MM/DD/YYYY MM/DD/YYYY YES AUTO-COMPUTE
NO
