A.

SCHEDULE OF ANNUAL PREMIUM FOR PERIOD – January 1, 2019 TO December 31, 2019 ANNEX E
PLAN CY 2019
Annual HMO ENROLMENT
Principal CONFIRMATION
Qualified Dependents (QD) FORMFamily
Extended - RANK & FILE
Members (EFM) EMPLOYEES Other Extended Family
(Room Benefit Member th Members (OEFM)
& LimitFOR SUBMISSIONPhilhealth TO LBPEA Office (24 Flr.,2 LBP Plaza)
Non-Philhealth ABL NOT LATER THAN
Philhealth AUGUST
Non-Philhealth 2 31,
Phil-2018
health Non-
Board) Philhealth
Page 1 of 2
2

PRINCIPAL MEMBER Last Name First Name PEC(60K per illness/member/yr)

M.I. PEC (60K /member/year)
Sex Civil Status
600 1 P150T 10,620SANTOS9,780 16,724 3 11,14 AL19,506 3
MARVIN P100T 15,732 W.18,482 M16,388 19,138
SINGLE
I.D. No. J253 Pay Grade 9 Unit/Dept/Branch BLSD/6LANDBANK PLAZA Group LEGAL SERVICES Mobile No. 09275307632
800 1 P200T 13,310 11,980 20,958 3 13,97 24,450 3 P150TGROUP19,608 22,358 20,426 23,176
Home Address DOOR 1, PAMANA INC., ARNAIZ AVE., MAKATI 2 CITY Email Address almarvinwsantos@gmail.com
1000 P250T 18,588 16,728 29,276 3 19,57 34,156 3 P200T 24,068 26,818 25,070 27,820
ENROLLED MEMBERS BASED ON CY 2018 DATE OF BIRTH PHILHEALT

CIVIL STATUS
4 WITH DENTAL

SEX
1100 P300T ENROLMENT
20,386 18,348 21,40 D P250T PLAN 26,476 BENEFIT? 29,226H 27,578PREMIUM30,328
(ONLY NEW QDs ARE ALLOWED): 4 MM YY MEMBER? (add dental if any)
D
1200 (Last Name,
P300T First Name,
21,208 Middle
19,088Initial) 22,26 P250T YES
27,798 NO YES
30,548 NO
28,956 31,706
PRINCIPAL MEMBER M S 8 05 06 90 1000   19,563
1300 QUALIFIED
EXISTING P400T 22,764
DEPENDENTS 20,488Relationship 23,91 P300T 29,564 32,314 30,796 33,546
0
1400 P400T 23,926 21,534 25,12 P300T 31,044 33,794 32,338 35,088
2
1500 P400T 24,970 22,474 26,22 P300T 32,592 35,342 33,950 36,700
ADDITIONAL QUALIFIED DEPENDENTS 0
1
Without access
(ALLOWED FOR(inpatient
CY 2019)& outpatient services) to Makati Medical Center (MMC), St. Luke's Medical Center (SLMC) Quezon City, Asian Hospital, Cardinal
Santos Medical Center and The Medical City (TMC)
MARGIE
2 W. SANTOS MOTHER F S 12 06 1959 800
The HMO will cover the equivalent of PhilHealth share in case of hospitalization of the enrollee.
  12,995
3
Premium for parents of single employees with age 71 or over but less than 76 y/o as of January 1, 2019, and previously enrolled in CY 2018 LBPEA contract
B. OPTIONAL DENTAL BENEFITS (For Principal and QD/s only) SUB-TOTAL FOR QD’s Additional Premium Required
EXISTING
EnrollmentEXTENDED
is conditional; FAMILY
availability is subject to required minimum of 1000 actual enrollees for CY 2019. Php 975.00/member
The dental benefits
MEMBERS/ OTHERmay be availed of in the network of accredited dental clinics under an open door availment system;
EXTENDED
Setting ofMEMBERS
FAMILY appointment required; package includes amalgam and light cure permanent filling up to two (2) teeth.
C. TERMS
(NEW AND CONDITIONS
EFMs/OEFMs NOT ALLOWED)
1. ENROLMENT FOR HMO CY 2019 SHALL BE BASED ON HMO CY 2018 COVERAGE/ENROLMENT N/A (as
N/Aapplicable). DELETION of QD’s, EFM’s/OEFM’s
and/or CHANGES IN PLAN SHALL NOT BE ALLOWED.
N/A N/A
2. Enrolment of additional Qualified Dependent/s (QDs) SHALL BE ALLOWED.
3. Enrolment of additional Extended Family Member (EFM) or Other Extended Family Member SUB-TOTAL
(OEFM) FOR EFMs/OEFMs
SHALL NOT ALLOWED. Including those enrolled
as Qualified Dependent/s for CY 2018. GRAND TOTAL (PRINCIPAL +QDs+EFMs+OEFMs) 32,518
4. The MINIMUM Plan for Principal Members (Rank & File employees) is PLAN 800;
PAYMENT
5. OPTIONS:
Qualified Please(QD),
Dependent markExtended
your choice withMember
Family a check (EFM)  . and Other Extended Family Member (OEFM)
A –5.1
FullQualified
Payment Dependent
– Total Premium (QD) in the  case of BMarried
- AvailmentEmployees
of PF Loan – Total Premium C – Combined Mode of Payment
Instructions for Payment:
- Spouse less than 71 years old as ofTerms date of of effectivity of coverage Instructions for Payment:
PF Loan Availment:
Full premium payment to be deposited
- Children, age of at least 15 days old to less Partial premium payment to be legitimate,
deposited to LBPEA
Interest at than
2% per 29 annum
years astoofbedate of effectivity
paid/collected of coverage; single/unmarried;
from whether, illegitimate;
to LBPEA or HMO FUND C/A No. 3402-
legally adopted, newly born children should be enrolled not laterperiod
than 30ofdays after birth. HMO FUND C/A No. 3402-1049-10 and original
salaries/benefits over a maximum ten (10)
1049-10 5.2and originalDependent
Qualified copy of deposit(QD) slip
in the months.
case of Single/Unmarried Employees copy of deposit slip (clearly labeled with name of
(clearly labeled with name of employee) employee) as proof of payment shall be submitted
- Parents less than 71 years old as of date of effectivity of coverage;
as proof of payment shall be submitted Maximum Loanable Amount shall be based on the to LBPEA Office (24th floor, LBP Plaza) not later than
- Parents age th 71 or over but less than 76 years old as of effectivity of coverage and previously enrolled under the CY2018 MediCard Coverage
to LBPEA Office (24 floor, LBP Plaza) number of years of service in LANDBANK. November 15, 2018 with remaining balance settled
3
not later than Contracted
November by the
15, LBPEA,
2018. please note special package . through PF loan.
- Children, age of at least 15 days old to less than 29 years as of date of effectivity of coverage; single and not gainfully employed; newly born
Number of Years in Service
children should be enrolled not later than 30 days after birth. Max Loanable Amount (Php) Mode Amount
5.3 Extended Family Members (EFM) – ENROLMENT OF NEW EFM/OEFM IS NOT ALLOWED (Php)
- Single/unmarried children, 29 years 5 years
old andandabove
abovebut less than 46 years75,000 old as of as of January Total1,Premium
2019 (whether legitimate, or illegitimate)
3 years to less than 5 25,000 Partial Premium Payment
- Married children, less than 46 years old as of January 1, 2019 (whether legitimate, or illegitimate)
years
- Parents of married employees, less than371
Below years old as of effectivity of 15,000
years coverage, and previously Balanceenrolled
for PF under
Loan the HMO Coverage contracted by
the LBPEA for CY2018.
CERTIFICATION/AUTHORIZATION/UNDERTAKING:
5.4 Other Extended Family Members (OEFM) to be treated separately from the group of Principals, QDs, and EFMs.
1. I hereby confirm enrollment of the undersigned and my qualified dependents/EFMs/OEFMs, as applicable (who were previously enrolled in the
ENROLMENT OF NEW EFM/OEFM IS NOT ALLOWED
CY2018 HMO contract with MediCard), under the terms and conditions governing the extension of said contract for CY 2019. In case the minimum
-
number Relatives
of enrollees by Consanguinity,
as required by lessMediCard
than 66 years is notold as of effectivity
reached, of coverage,
I further confirm and myenrolled
agreement undertothebe2018 LBPEAtogether
enrolled HMO Coverage:
with my qualified
Children (other than those qualified as QDs or EFMs); Grandparents; Grandchildren;
dependents/EFMs/OEFMs, as applicable enumerated above and settle the corresponding premium due declared to be 15-25% higher Brothers & Sisters; Aunts & Uncles; and Nieces
than & Nephews.
those for
- Relatives by Affinity, less than
CY 2018 based on my expressed payment option as above. 66 years old as of effectivity of coverage, and enrolled under the 2018 HMO Advisory Group HMO coverage:
Parents-in-law;
2. I certify that Children-in-law;
all the information containedand Brothers/Sisters-in-law.
in this form are true and correct to the best of my knowledge and belief, and that any misrepresentation as
For newly
6.to material factenrolled
indicated Principal Member
herein shall be a and
cause his/her
for theQD/EFM/OEFM may select different
cancellation/discontinuance of the HMOPlans coverage
under MediCard.
and that However, a QD/EFM/OEFM
I am fully aware that I can becannot
civilly, be
enrolled
criminally in a Plan
and/or that is higherliable
administratively than for
thatanyof the
falsePrincipal Member.
declaration and/or misrepresentation on my part.
The Principal
3.7.I undertake to complyMember mustpremium
with the enroll his newborn
payment QD/s (must
requirements be at
based onleast 15 days options
the payment old to qualify as member/s)
I have selected within
as indicated thirty (30) days after birth;
above.
otherwise,
4. I certify furthermoremembership will fully
that I have be allowed only the
understood in the nextand
terms semester.
conditionsA newly-married
of this confirmationemployee must enroll
of enrollment his spouse
application andwithin (30) days after
the enrollment date of
guidelines
marriage
indicated in thefor memo
immediate dated coverage;
August 10, otherwise
2018 re:membership
Enrollment will for CYbe 2019
allowedHMO only in the next
Coverage for semester.
LANDBANK officers and rank-and-file employees.
Pre-Existing
5.8.I hereby authorize Conditions (PEC) Association (LBPEA) or any of its duly authorized representative to act as my own representative (a) to negotiate and
LBP Employees’
8.1 PEC are waived
enter into a contract with MediCardfor the principal members;
(including claimshis/her
and QD/s
suits) and
and EFM/s
those of(enrolled
my QD/s, in CY 2018and
EFM/s as QD or EFM).(b)However,
OEFM/s; to obtainthe coverage
a loan for myforaccount
PEC forfrom
OEFMs
shall be
the Provident up toand
Fund P60,apply
000.00 theper memberthereof
proceeds per year tobut notany
cover to exceed
premium ABL,deficiencies
regardless of and thetomember’s plan.
cause deductions from my salaries/benefits of such
8.2 Anasillness
amount/s may be or needed
condition toisrepay
considered to have
the PF Loan; (c)been
I alsoinhereby
existence prior toLBP-PFO
authorize the effective
to allowdatetheofaforesaid
coveragetransactions
if: for said purposes indicated.
6. Moreover, a. Any professional
I hereby hold LBPadvice or treatment
Employees’ was obtained
Association (LBPEA) for freesuch
andillness or condition;
harmless from any claims or liabilities that may arise as a consequence of the
b. Such illness
implementation of the or condition
authority was granted.
herein in any way evident to the member; and
7. This HMO c. membership
The onset and pathogenesis
shall be governed of by
suchtheillness
termsorand condition
conditionshas agreed
starteduponwhether or not
by LBP the Member
Employees’ is aware(LBPEA)
Association of suchand
illness or condition.
MediCard.
8.3 IThe
8. Should fail following
to settle any are automatically considered
premium installments dueasand/or
pre-existing
submitconditions if treatment
proof of payment is sought
within within the
the deadline set,first
it istwelve (12) months
understood of premiums
that the coverage. due
shall beAbnormalities
charged against of anasal septum
PF loan taken & turbinate’s;
in my account Arthritis;
and toBronchial
be repaidAsthma; Buerger’s
as authorized Disease;
in the Calculi, Urinary from
foregoing/deducted Tract;my
Cataracts,
LANDBANK Glaucoma;
salary/orDiabetes
any
Mellitus;
benefits due me. ENT Tumors and other tumors (benign or malignant); Endometriosis, uterine myoma, and ovarian cyst; Gallbladder stones; Goiter;
Hemorrhoids anal fistulae; Hernia; Hypertension; Prostate Disorder; Sinus conditions requiring surgery; Tuberculosis; Tumors of the skin, muscular
Note: Since thisbreast,
tissue, will onlybonebe oran extension,ofwe
malignancies willorfollow
blood the same
bone marrow; premium
urethral and same benefits
stenosis/urinary of ourvaricose
tract strictures; CY 2017-2018
veins) Contract; though a
reduction of more than 5% in our current head count shall mean a re-computation in our premium rates.
Please
SIGNATURE prepare three (3) copies of this form: Original – MEDICard copy; Duplicate –DATE:
OF EMPLOYEE: LBPEA copy; Triplicate – Employee’s receiving copy
DEADLINE FOR SUBMISSION OF CY2019 HMO ENROLMENT CONFIRMATION FORM IS ON AUGUST 31, 2018.
DEADLINE FOR PREMIUM PAYMENT/SUBMISSION OF ORIGINAL COPY OF DEPOSIT SLIP IS ON NOVEMBER 15, 2018.