HEALTH CARE QUALIFIED DEPENDENT ENROLLMENT FORM Policy Year Nov. 15, 2021 - Nov. 14, 2022

1/10/22, 9:03 PM HEALTH CARE QUALIFIED DEPENDENT ENROLLMENT FORM Policy Year Nov. 15, 2021 - Nov.
15, 2021 - Nov. 14, 2022
HEALTH CARE QUALIFIED

DEPENDENT ENROLLMENT FORM
Policy Year Nov. 15, 2021 - Nov.

14, 2022
This form captures information relevant to the enrollment of FREE and ADDITIONAL
Dependents of our eligible talent under the EMAPTA Health Care Benefit Program.
Please note that this form needs to be completed within 30 calendar days from the effective
date of eligibility / regularization, otherwise, enrolment for HMO for your qualified dependent(s)
for the current policy year shall be forfeited and shall be deferred to the next policy year starting
November 15, 2022.
IMPORTANT!!!
Accuracy in filling out this form is essential. Data generated from this form shall be considered
final and will be used in the enrolment of your Dependent(s). Any information that needs to be
corrected due to inaccurate information provided in this form will require replacement of Health
Care Card and the replacement fee shall be charged to yourself.
QUALIFIED DEPENDENT ENROLMENT GENERAL GUIDELINES

Enrollment of Qualified dependents in the EMAPTA Health Care Benefit Program follows an Enrollment
Hierarchy:
SINGLE
1. Parents (up to 65 years old, minimum of 6 months to stay in the program)

2. Siblings, from eldest to youngest (15 days to 21 years old, minimum of 6 months to stay in the
program)
SINGLE-PARENT
1. Child/ren, from eldest to youngest (15 days to 21 years old, minimum of 6 months to stay in the
program)
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1/10/22, 9:03 PM HEALTH CARE QUALIFIED DEPENDENT ENROLLMENT FORM Policy Year Nov. 15, 2021 - Nov. 14, 2022
2. Parents (up to 65 years old, minimum of 6 months to stay in the program)

MARRIED
1. Legal Spouse (up to 65 years old, minimum of 6 months to stay in the program)
program)
WIDOW
program)
Skipping of hierarchy maybe allowed on certain circumstances. Documentary evidence is required to

prove qualification to skip enrollment hierarchy. If you need to skip our enrollment hierarchy, please do
not hesitate to reach out to your HR Business Partner or any member of the People Operations
Division.
FREE Dependent
free qualified dependent packaged as part of the Principal's Health Care Coverage, paid for by
EMAPTA/Client.
ADDITIONAL Dependent
additional qualified dependent to be paid for by the employee via salary deduction. Enrollment of
Additional Dependent is an accommodation and should not be construed as part of the employee
benefit package. EMAPTA reserves its right to cease offering coverage for Additional Dependent/s as it
deems necessary given proper notice, without the need for justification.
Deductions for ADDITIONAL Dependent's premium cost shall start on first payday immediately
following confirmation of enrollment until November 30, 2022 payroll. Pro-rated Amount of premium
cost shall be confirmed by People Operations.
IMPORTANT!!!
Employee cannot add, and/or modify enrolled dependents within the policy year, except under the
following circumstances. Addition and/or modification must be executed within the below enrollment
window:
1. Marriage (within 30 calendar days from date of marriage);

2. Newborn child (within 30 calendar days from date of birth of newborn);
3. Death of enrolled dependent (within 30 calendar days from date of death of dependent);
4. Migration of enrolled dependent (within 30 calendar days from date of departure of dependent);
5. Enrolled dependent being covered by another HMO Plan (within 30 calendar days from enrolled
dependent's coverage by another HMO Plan);
Required supporting documents that needs to be submitted by the employees:
If Singe / Single Parent - birth certificate of principal and dependent(s) for enrollment
If Married - marriage certificate and birth certificate of child/ren
Above documentary requirements should be sent over to hr@emapta.com using this subject line:
Health Care Enrollment Supporting Documents | (Your Full Name) after completion of this
form. People Operations Team shall not process applications without proper documentation to support
the enrollment, in compliance to the set guidelines of our provider.
Separated employee shall not recover cost for any payment made regardless if there is utilization or
otherwise. Premium costs are being paid by EMAPTA in advance. Hence, in case of separation,
premium applicable to the month of separation of the employee shall be deducted in full amount from
the employee's final paycheck.
For inquiries and clarifications, you may reach out to your HR Business Partner and/or any member of
the People Operations Division thru hr@emapta.com prior to submitting your response to this form.
YOUR INFORMATION
This section captures your personal information.
1. Your Employee ID/Code *

Kindly indicate your Employee ID # in the following format 00-0000 (i.e., 10-0001)
If you don't know your Employee ID #, kindly indicate 00-0000 (applicable for new hires only).
21-2328
2. Your Last Name *
Olivar
3. Your First Name *
Hannah
4. Your Middle Name *
Flores
5. Your Name Suffix

Sr., Jr., II, III, IV, etc.
Enter your answer
6. Your Date of Birth *
8/10/1991
7. Your Gender *
FEMALE 
8. Your Updated Mobile Phone Number *

Please indicate your current mobile phone number with the leading country code 63 (i.e.,
639171234567)
639176225273
9. Your Division/Department. If deployed to a client, Your Account/Client Affiliation *
E2Open
10. Your Office Site Assignment *
BDO (BDO Equitable Tower, Makati City) 
11. Your Preferred Email Address for Communications *
hfolivar@gmail.com
12. Date of Hire (Start Date with the Company) *
11/22/2021
13. HMO Eligibility *
Upon Hire
Upon Regularisation
YOUR REQUEST
Please select the action you wish to execute in relation to your Health Care Dependents. Please note
that you can only choose one action at a time. If you would like to execute more than one (1) action,
you will need to fill out this survey for each action you wish to execute. For instance, if you would like
to add one (1) Free Dependent and one (1) Additional Dependent, you will need to fill out this survey
for each dependent.
14. What do you want to do? *
I want to ENROLL a FREE Dependent 
FREE DEPENDENT ENROLMENT

This section captures information for your FREE Dependent.
IMPORTANT!!!
Accuracy in filling out this form is essential. Data generated from this form shall be considered final and
will be used in the enrolment of your FREE Dependent. Any information that needs to be corrected due
to inaccurate information provided in this form will require replacement of Health Care Card and the
replacement fee shall be charged to yourself.
15. Your current Marital Status *
SINGLE (Unmarried, without Child/ren) 
16. Your Relationship to your FREE Dependent *

Single
SIBLING (15 days to 21 years old; eldest to yo… 
17. Your FREE Dependent's Last Name *
Olivar
18. Your FREE Dependent's First Name *
Binhi
19. Your FREE Dependent's Middle Name *
Flores
20. Your FREE Dependent's Name Suffix

Sr., Jr., II, III, IV, etc.
Enter your answer
21. Your FREE Dependent's Gender *
FEMALE 
22. Your FREE Dependent's Date of Birth *
7/20/2002
23. Your FREE Dependent's Marital Status *
SINGLE 
SKIPPING HIERARCHY
Please note that your Dependent enrollment shall still be subject to review by our Benefits
Administrator. If you are skipping the established hierarchy, you may be asked to present documentary
proof of qualification to skip hierarchy. Our Benefits Administrator will get in touch with you to discuss
this in detail.
Failure to provide documentary proof of qualification to skip hierarchy shall be sufficient ground to
disapprove the enrollment of your nominated FREE and/or ADDITIONAL Dependent into our Health
Care Benefit Program.
24. Are you skipping Hierarchy? *
Yes 
25. Please choose the specific circumstance that applies to your case *
My dependent(s), following hierarchy rule...
already has own Health Care Coverage 

26. Please expound on why you think are qualified to skip the Hierarchy Rule. *
My Parents still has their own existing Health Care Coverage.
SUPPORTING DOCUMENTS
All applications should be accompanied by a supporting document to be sent to hr@emapta.com with
this subject line: Health Care Enrollment Supporting Documents | (Your Full Name).
Below are the applicable supporting documents:
1. If enrolling parent(s) - talent and parent(s) birth certificate
2. If enrolling sibling(s) - talent and sibling(s) birth certificate
3. If enrolling child/ren - talent and child/ren's birth certificate
4. If enrolling spouse - marriage certificate
27. I confirm that after filling out this form, I will submit the applicable supporting
document(s).
Yes
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1/10/22, 9:03 PM HEALTH CARE QUALIFIED DEPENDENT ENROLLMENT FORM Policy Year Nov. 15, 2021 - Nov.

15, 2021 - Nov. 14, 2022

HEALTH CARE QUALIFIED

Policy Year Nov. 15, 2021 - Nov.

QUALIFIED DEPENDENT ENROLMENT GENERAL GUIDELINES

1. Parents (up to 65 years old, minimum of 6 months to stay in the program)

2. Parents (up to 65 years old, minimum of 6 months to stay in the program)

Skipping of hierarchy maybe allowed on certain circumstances. Documentary evidence is required to

1. Marriage (within 30 calendar days from date of marriage);

Required supporting documents that needs to be submitted by the employees:

If Married - marriage certificate and birth certificate of child/ren

1. Your Employee ID/Code *

2. Your Last Name *

3. Your First Name *

4. Your Middle Name *

5. Your Name Suffix

Enter your answer

6. Your Date of Birth *

8. Your Updated Mobile Phone Number *

9. Your Division/Department. If deployed to a client, Your Account/Client Affiliation *

10. Your Office Site Assignment *

BDO (BDO Equitable Tower, Makati City) 

11. Your Preferred Email Address for Communications *

12. Date of Hire (Start Date with the Company) *

13. HMO Eligibility *

14. What do you want to do? *

I want to ENROLL a FREE Dependent 

FREE DEPENDENT ENROLMENT

15. Your current Marital Status *

SINGLE (Unmarried, without Child/ren) 

16. Your Relationship to your FREE Dependent *

SIBLING (15 days to 21 years old; eldest to yo… 

17. Your FREE Dependent's Last Name *

18. Your FREE Dependent's First Name *

19. Your FREE Dependent's Middle Name *

20. Your FREE Dependent's Name Suffix

Enter your answer

21. Your FREE Dependent's Gender *

22. Your FREE Dependent's Date of Birth *

23. Your FREE Dependent's Marital Status *

24. Are you skipping Hierarchy? *

already has own Health Care Coverage 

My Parents still has their own existing Health Care Coverage.

Below are the applicable supporting documents:

1. If enrolling parent(s) - talent and parent(s) birth certificate

2. If enrolling sibling(s) - talent and sibling(s) birth certificate

3. If enrolling child/ren - talent and child/ren's birth certificate

4. If enrolling spouse - marriage certificate

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