HOW TO FILL UP THE FORM PROPERLY

1. Use check mark for all boxes that requires answer.

2. Put "N/A" if not applicable.
3. Do not forget to answer all necessary information, e.g Height,
Weight, Blood Pressure, Job Title, Name of Office/Business

1. Tick left check box if a dependent is applying.

2. Do not left blank the following columns as it is necessary to
identify the dependent's data.
3. You can lower the plan type of the dependents or can be the
same with the Principal enrollee.
 1. For Individual & family plans, standard beneficiaries are
immediate family members
2. Check the box on the left side if the beneficiaries is same as
above dependents. Please make sure to choose corresponding
numbers.

1. For Individual & Family plans, answer the medical questionnaire

without leaving any blanks on the check box.

1. For each "YES" answers in Statement of Health, you must

complete the following information below.
 1. Answer Yes or No, using a check mark on the right side.

1. You must read our General Terms and Conditions for you to
understand the plan you're enrolling to. Because not all
information is coming from your Agent, just can ask if you have
any confusions, inquiries on any part of it.
1. Most important part of the form, signature portion.
Reminders:

Please note that age eligibility for application is from 15

days old to 60 years and 5 months old only.
Incomplete details might cause delay of the application.
For Individual application- provide 1 valid ID (front and back
clear scanned copy)
For Family application- provide 1 each valid ID Principal
/Enrollee (husband & wife, front and back clear scanned
copy)
For child enrollee, must provide Birth Cert (PSA copy, clear
scanned)
Provide Marriage cert for Married Enrollees
If dependent is sibling, 21yo below are eligible to apply.
For Non-Filipinos/Foreign Enrollees (provide ACR) (ANNUAL
Mode of Payment must apply)
The submitted application is under evaluation of 7 to 14
working days upon receipt of complete documents.
Any changes to make once the application has been
submitted will take more business days processing the
whole application.
Send all complete requirements to my email:
arianecomboy.maxicare@gmail.com