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Group Medical Insurance Enrollment and Change Form — NON US PLAN Please email or fax your completed enrollment form to: email: benefitsatsea@rccl.com or fax: 305-539-6232, Royal Caribbean, Attention: International Officers Medical Plan Reason for Enrollment: New Enrollee Cicoverage/Status Change — []Cancel It you selected Coverage’Status Change or Cancel, you must attach supporting documentation to your completed form, Employes Information ceiDe 549795 Date of Hire: /EMB Lo Name: ADATO ADR ic} ast Nile rat Secal Seay Number W applicable Home Steet Address: /0 ZADANG STREET “BNEANGGAY ALAM BONE : Quezon Cay NCR 111 PHILIPPINES ay ~ Stale Postal Code Country Phone: +63920424 4015" Email Address: al/oyrace @gmail-COM sus Address:_~ Marital Status: Single ]Divoreed Gender: [JMale Date of Binh: / 2/09/1987 married — ClWidowea (Female MMIDDIYY ‘Are you a US Citizen or Resident: ClYes fo Nationality: 7412/0 Employer: Royal JAGelebrty ClAzamara Name of Current Ship Assignment CELEBRITY ECLiPse Dept: fAflerine C)Hotel Cother: Position 1. Sie \mas WER Elect Medical Plan Coverage Level and Monthly Rates Please Note: Tier Bete NON US Raw Lesecarempun 7 - Election ef you oe aU Chen Employee Only | $0.00 Seomaeuae Employee & Spouse Oi stooss vs. Employee & Children) (Employee & Children Only, No Spouse 1123.13 homepage 2 Employee & Family (Employee, Spouse & Children) Os205.40 acorn AUTHORIZATION: Please read carefully and Sign & Date: "hereby cory that have rad a statements contained, n alton to al stachments, or they have bean read to me, and the sateme Complete othe best of my knowledge and betet | understand that any mlsropresentaion conta eran wll vos the insurance and be fore. | Understand if | elect medical coverage for my eligible dependents, | wil be charged the applicable amaunt on a quartet bass. ‘The undersigned authorizes any licensed doctor, practioner ofthe healing ats, hospital cic heath related facity, pharmacy, goverment agency, Insurance agency, insurance compen. group poy holder, employee or Benefit pan administrator having information as to the are, advice, vestment, agnosis or prognosis, of any physical or mental condtion or the nana and employment status of Ue invidual to provide this infarmaton iG Cioa Heth Bonet _ Za - 20/19/20& Employee Signature Date: MM/DDIYYYY For Company Use: RCCL Inia Hire Dae: lig. Date: Ett. Date: sob Code: lon Year 2018 -16- Page2: EE ld # 549795 Employee Name: ALDPYN —®. _ ADATO (Last, First, Middle Initial) Gender OSes Home Address (if different than page one) = OwOF atonaty, Om OF oa Om OF eam Ow OF Sus OM OF : pendent Information — Please complete for each dependent you are enrolling in the Medical Plan. Dependent Children Age 19 to 23, please indicate Name and Address of College/University and Student Status Dependent Name: Name of College/University Student Status: Fulltime [Part-time Street Address: city: State: Postal Code’ Country: Dependent Name: Name of College/University ‘Student Status; CJFull-ime [] Parttime Street Address: city State:_ Postal Code: Country Ifyou are a late entrant* into the plan, the following questions must be answered. For any questions answered YES, please provide details ofthe medical condition on a separate sheet and attach Itto this application. fos ABio | EnplcveetDevenden Name 4. ts anyone curenty Pregnant, hsplaized, or disablea? | Yee JAflo | env 2. Has anyone ever been diagnosed, treated or tested EmplayoerDependent Name postive for Acquired Immune Deficiency Synrome (alos), | Yes JAN AIDS Related Complex (ARC), Lymphadenopathy Syndrome or any Immune System Disorder? 3. Has anyone ever been diagnosed, treated or tested Dyes JANo | Employee(Dependent Name: positive for Cancer, Diabetes, High Biood Pressure or any Cardiac, Cardiovascular, Heart or Condition? 44. During the last 3 months, has anyone been diagnosed, | ClYes [No _| EmioyeelDopendent Nome treated (including medications or consultations) or tested for any medical or mental or nervous condition? 55. During the last 3 months, has anyone been advised or | Ces Fic EmployeeiDependent Name. recommended to have testing, treatment or surgery for any medical or mental or nervous condition? 6. Has anyone ever been rejected, rated, or declined for | C¥es_JAIMlo | EmployeeIDependen Name: any other Health, Life or Disability insurance? + Rate erat defined as an employee andlor dependent Wats envoling Yor Ue Wate into He plan at was previously aise To enrol “17-