DISTRIBUTION CHANNEL INFORMATION

AGENT/ BROKER CODE: _________________________

MYMAXICARE APPLICATION FORMAPPLICANT'S INFORMATIONNOTE: TO FACILITATE PROCESSING OF THIS APPLICATION, PLEASE ACCOMPLISH THIS FORM IN FULL. KINDLY WRITE IN BLOCK LETTERS AND CHECK THE APPROPRIATE BOX WHERE APPLICABLE

NEW APPLICANT ADDITIONAL APPLICANT REAPPLICATION TRANSFEREE

Type of Coverage

Plan Type

Mode of Payment

Dental Coverage

Philhealth Member

Individual

Platinum Plus

Annual

Yes

Yes

Family

Platinum

Semi-Annual

No

No

Group/Corporate

Gold

QuarterlySilver

Specify Name: ___________________

PAYMENT OPTIONCREDIT CARD OVER-THE-COUNTER BANK MAXICARE OFFICE CASHIER

PERSONAL INFORMATION (PRINCIPAL/ PAYOR)LAST NAME

CIVIL STATUS

NO. OF CHILDREN

RESIDENCE ADDRESS (NO., STREET, VILLAGE, BRGY., TOWN/MUNICIPALITY, PROVINCE, ZIP CODE)

CONTACT PERSON & MAILING ADDRESS (NUMBER, STREET, VILLAGE, BRGY, CITY, ZIP CODE)(IF UNDER AN AGENT/BROKER PLEASE INDICATE AGENTS/BROKERS ADDRESS)

FIRST NAME

GENDER

JOB TITLE

MIDDLE NAME

EMAIL ADDRESS

NAME OF OFFICE/BUSINESS

EXTENSION NAME (JR, SR,III) DATE OF BIRTH (MM/DD/YYY)

HOME NUMBER

BLOOD PRESSURE (mmHg)

NATIONALITY

SSS/GSIS//PHILHEALTH (If available)

Encircle the appropriate institution that issued the ID number

AGE

MOBILE NUMBER

HEIGHT (FT.iN)

OFFICE PHONE NO.

WEIGHT (LBS)

OFW ID NUMBER:

TAX IDENTIFICATION NUMBER (TIN) (if available)

PERSONAL INFORMATION (DEPENDENT/S)

1

2

3

4

5

if Applying

FULL NAME OF

APPLICANTRELATION AGE GENDER DATE OF BIRTH

(MM/DD/YYY)CIVIL

STATUS HEIGHT WEIGHT BLOOD PRESSURE

PHILHEALTH MEMBER?

(Y/N)

DENTALCOVERAGE

(Y/N)OCCUPATION

DEPENDENTS PLAN TYPE Platinum Plus Platinum Gold SilverFOR FAMILY AND GROUP ACCOUNTS: 15 DAYS OLD UP TO 21 YEARS AND 5 MONTHS OLD ARE ACCEPTABLE AGES FOR MINOR DEPENDENTS. CHILDREN WHO ARE 22 YEARS OLD AND ABOVE WILL BE CONSIDERED AS INDIVIDUAL APPLICANTS.

BENEFICIARIES (Note: Standard beneficiaries are immediate family members)

1

2

3

4

5

check the box on the left side if the beneficiaries is same as above dependents. Please make sure to choose correct corresponding numbersName Relationship to Principal Birthday Age

STATEMENT OF DETAILSI/We hereby clearly understand and agree that failure to declare illnesses in the following questions (referring to any proposed member) will invalidate future claims and that the corresponding details of which will be indicated in Statement of Details.

MEDICAL QUESTIONNAIRE1. Has any proposed member/s complained of any untoward symptoms pertaining to diseases or conditions of:

1a. The brain or nervous system – such as loss of consciousness, dizziness, headaches, seizure disorder, paralysis, mental retardation, stroke?1b. The cardiovascular system – such as heart disease, rheumatic fever, palpitation, shortness of breath, chest pain, high or abnormal blood pressure, heart murmur, etc.?1c. The peripheral vascular diseases – such as varicose veins, phlebitis, aneurysm, arthritis, embolism, etc.?1d. The digestive system – such as ulcer, gall bladder disorder, liver disease, colitis, chronic diarrhea, fistula, hemorrhoids, colon or intestinal disorder, hernia, malabsorption and pancreatitis?1e. The genito-urinary system – such as renal colic, stone, bladder or kidney disorder, stricture, prostate disorder, syphilis, or venereal disease, etc.?1f. The metabolic system – such as diabetes, gout, thyroid or adrenal disorder etc. and immune system disorders including acquired immune deficiency syndrome (AIDS), AIDS-related complex (ARC) etc.?1g. The musculo-skeletal system – such as back sprain, neck or back disorder arthritis, fractures, slipped disc, dislocation, joint problems, physically handicapped, etc.?1h. The respiratory tract – such as asthma, tuberculosis, spitting or coughing blood, allergies, emphysema, lung/chest disease of any kind, etc.?

2. Has any proposed member/s ever received a medical advice or treatment for, or ever had any known indications of any breast condition, infertility or other female problems?3. So far as you know, is a proposed member/s now pregnant? Expected delivery date: (mm-dd-yyyy) __________________________

3a. If YES, is caesarean section anticipated?

4. Has any proposed member/s ever received medical advice or treatment for:4a. Disease of eyes, ears, nose or throat?

4b. Any skin disorders, cancer, psoriasis, keratosis, herpes, etc.?4c. Cancer?4d. Tumor?4e. Alcoholism or drug dependency?4f. If YES to 4e, is he a member of a support group?

5. Has any proposed member/s ever had any:5a. Hospitalization/Surgery? If YES, please give details ____________________________________________________________________________________________

6. Any congenital disorders?

YES NO

Form Template Control: Underwriting and Enrollment Fulfilment/ August 7, 2017 /FO-UEF-0.027/Rev.01

BENEFICIARIES (Note: Standard beneficiaries are immediate family members)For “YES” answers in Statement of Health, please complete the following information. You may use a separate sheet for more details or attached pertinent documents related to the declarations.

QUESTIONNO. FIRST NAME DIAGNOSTIC/MEDICATION INCLUSIVE DATES NAME OF HOSPITAL & DOCTOR

Form Template Control: Underwriting and Enrollment Fulfilment/ August 7, 2017 /FO-UEF-0.027/Rev.01

HEALTHCARE COVERAGE

1. Were you a previous member of any Health Maintenance Organization (HMO)?

If “YES”, which HMO: ___________________________________________________________________________________________________________________

When did your former membership begin _________________________and end ___________________________

2. Have you ever been treated or examined or hospitalized while you were a member of this HMO?

If “YES”, please list the date of last exam or treatment and the place of confinement _________________________________________________________________

3. Have you filed any claims for reimbursement of medical services with your previous HMO?

If “YES”, what is the status? ______________________________________________________________________________________________________________

4. Have you ever been rejected for medical insurance including an HMO plan, or have been offered insurance at higher (rated up) premiums?

If “YES” please explain briefly _____________________________________________________________________________________________________________

YES NO

GENERAL TERMS AND CONDITIONS

1. The Member’s application for MyMaxicare healthcare program shall be assessed by Maxicare upon receipt of this Application Form and the corresponding Membership Fee. In the event that the

application is disapproved for any reason whatsoever, the Membership Fee shall be refunded to the applicant. Maxicare shall have no obligation to disclose the reason for such disapproval.

2. The coverage of MyMaxicare shall commence upon Maxicare’s approval of the application and the Member’s receipt of the Maxicare Card.

3. Subject to Maxicare’s option not to renew the coverage for any justifiable reason, the Member can renew his coverage by paying the Membership Fee on or before the due date.

4. It shall be the Member’s obligation to obtain from Maxicare the Membership Agreement and any amendments thereto, which are integral parts of this Application Form and which shall govern the

rights and obligations of the parties.

5. For the duration of his membership, this Application Form shall serve as the Member’s authorization to any healthcare facility, physician, surgeon, or other healthcare professional to provide

Maxicare, its agents or employees, all information relevant to his application, including any medical examination or treatment furnished to him, or to any illness, injury or condition that he had or

may have. This information is requested for the purpose of evaluating and processing his application, request for change in coverage, or to determine his eligibility for certain benefits.

6. The Member warrants that the information given in this Application Form are true and correct. Nondisclosure or falsification of any information shall be a ground for termination or suspension of

membership and/or denial of availment, without prejudice to any other legal remedies that may be available to Maxicare.

7. The Member hereby authorizes Maxicare to: (i) obtain, examine and process his personal information, medical records or any other medical advice in connection with the benefits/claim availed

using the Maxicare Card or pursuant to the agreement between Maxicare and the Member; and (ii) disclose such information to the Member’s representative, if applicable. The Member shall hold

Maxicare free and harmless from and against any and all suits or claims, actions or proceedings, damages, costs and expenses, including attorney’s fees, which may be filed, charged or adjudged

against Maxicare or any of its directors, stockholders, officers, employees, agents or representatives in connection with or arising from the use and disclosure by Maxicare of the Member’s medical

records and other personal information pursuant to the Membership Agreement and any amendment thereto.

I HAVE READ THE MAXICARE APPLICATION FORM, CONDITIONS OF ENROLLMENT AND AUTHORIZATION STATEDABOVE AND FULLY UNDERSTAND AND AGREE TO THEM.

SIGNATURE OF APPLICANT (Or legal guardian)Signature over printed name

DATE

-This portion is to be accomplished by Agents/Brokers-

AGENT/BROKER’S NAME ADDRESS CONTACT NOS.