STATEMENT OF DETAILS

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.
QUESTION
FIRST NAME DIAGNOSTIC/MEDICATION INCLUSIVE DATES NAME OF HOSPITAL & DOCTOR
NO.

HEALTHCARE COVERAGE
YES NO

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 _____________________________________________________________________________________________________________

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 STATED
ABOVE AND FULLY UNDERSTAND AND AGREE TO THEM.

SIGNATURE OF APPLICANT (Or legal guardian) DATE

Signature over printed name

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

AGENT/BROKER’S NAME ADDRESS CONTACT NOS.

MARIA ARIANE A. COMBOY 192 SCOUT FUENTEBELLA EXTENSION, QUEZON CITY +639333368039 / +639955302368

BUSINESS PARTNER/MERCHANT’S NAME ADDRESS CONTACT NOS.

Form Template Control: Underwriting and Enrollment Fulfillment/February 15, 2018/FO-UEF-0.022/Rev.03