HMO ENROLLMENT FORM

I. PERSONAL DATA
Name of Employee:

Employee Number:

(Last Name/First Name/Middle Name)

Position/Rank:

Civil Status (Pls check):

Single
Married

Department/Branch:

Date Hired:
Single Parent
Date of Birth:

II. ELIGIBILITY REQUIREMENTS

Principal

Regular Employees who are up to 65 years old

Qualified Dependents:
Single Employee

> Parents up to 65 years old

Married Employee

> Legal Spouse up to 65 years old

> Legitimate, legally adopted or acknowledged natural children who are 14 days old
up to 21 years old.
> Special Children covered (no age limit)
Note: If a dependent member reaches 22 years old while the policy is in force, he/she will be
covered up to the expiry date.

Single Parent Employee

> Parents up to 65 years old OR Children 14 days old up to 21 years old, unmarried and officially
dependent to the Principal Member
Note: If a dependent member reaches 66 years old or 22 years old while the policy is in force,
he/she will be covered up to the expiry date.

III. LIST OF QUALIFIED DEPENDENTS

NAME
(Last Name, First Name, Middle Name)

Date of Birth

Age

____________________________
Sgnature of Employee
Note : Employee who is on probation will be enrolled only upon confirmation regularization status.

Gender

Relationship to
Principal