318/22, 2:39 PM HEALTH CARE QUALIFIED DEPENDENT ENROLLMENT FORM Policy Year 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 od, 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) 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) hitps:forms.office.com/Pages/ResponsePage.aspx7id=EW, KW. 7IEGOFIB}t_1KSBIBMGno5JuG3XinZO_yJUMO!QUEFROUABTZBXMVIARF... 1/8‘ie22, 240 PM HEALTH CARE QUALIFIED DEPENDENT ENROLLMENT FORM Policy ear Nov. 15,2021 - Nov. 14,2022 2.Child/ren, from eldest to youngest (15 days to 21 years old, minimum of 6 months to stay in the program) WIDOW 1. Child/ren, from eldest to youngest (15 days to 21 years old, minimum of 6 months to stay in the 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 enroliment 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 Iitps:foms.ofce.comPPages/ResponsePage.aspxid-EW, Kw. 7TEGOFIBt 1KSBIBMGinoSJuGSXhnZO_yJUMO1QUEFROUdBTZBXNVARF... 218318/22, 240 PM HEALTH CARE QUALIFIED DEPENDENT ENROLLMENT FORM Policy Year Nov. 15, 2021 - Nov. 14, 2022 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 (ie., 10-0001) If you don't know your Employee 1D #, kindly indicate 00-0000 (applicable for new hires only). 00-0000 2. Your Last Name * Faller 3. Your First Name * April Anne. 4. Your Middle Name * Javier 5. Your Name Suffix St, Sta MM, WV, ete. N/A hitps:forms.office.com/Pages/ResponsePage.aspx7id=EW. KW. 7/EGOFIB}t_1KSBIBMG1no5JuG3XinZO_yJUMO!QUEFROUABTZBXMVIARF... 3/8318/22, 240 PM HEALTH CARE QUALIFIED DEPENDENT ENROLLMENT FORM Policy Year Nov. 15, 2021 - Nov. 14, 2022 6. Your Date of Birth * 4/18/1980 7. Your Gender * FEMALE v 8. Your Updated Mobile Phone Number * Please indicate your current mobile phone number with the leading country code 63 (ie, 639171234567) 639509037789 9. Your Division/Department. If deployed to a client, Your Account/Client Affiliation * Uplift Healthcare Solutions 10. Your Office Site Assignment * JMT UMT Corporate Condominium, Pasig City) 11. Your Preferred Email Address for Communications * fey faller09@gmail.com 12. Date of Hire (Start Date with the Company) * hitps:forms.office.com/Pages/ResponsePage.aspx7id=EW. KW. 7IEGOFIB}t_1KSBIBMG1n05JuG3XinZO_yJUMO1QUEFROUABTZBXMVIaRF... 4/88/22, 240 PM HEALTH CARE QUALIFIED DEPENDENT ENROLLMENT FORM Policy Year Nov. 15, 2021 - Nov. 14, 2022 3/21/2022 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? * | want to ENROLL a FREE Dependent Vv FREE DEPENDENT ENROLMENT This section captures information for your FREE Dependent. IMPORTAN’ 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-PARENT (Unmarried, with Child/ren) 16. Your Relationship to your FREE Dependent * Single-Parent hitps:forms.office.com/Pages/ResponsePage.aspx7id=EW, KW. 7/EGOFIB}t_1KSBIBMG1no5JuG3XinZ0_yJUMO!QUEFROUABTZBXMVIaRF... 5/88/22, 240 PM HEALTH CARE QUALIFIED DEPENDENT ENROLLMENT FORM Policy Year Nov. 15, 2021 - Nov. 14, 2022 CHILD (15 days to 21 years old; eldest to youn... 17. Your FREE Dependent's Last Name * Yabut 18. Your FREE Dependent's First Name * Sebastian Grey 19. Your FREE Dependent's Middle Name * Faller 20. Your FREE Dependent's Name Suffix St, Jt, HM, WV, et. N/A 21. Your FREE Dependent's Gender * MALE Vv 22. Your FREE Dependent's Date of Birth * 9/14/2016 hitps:forms.offie.com/Pages/ResponsePage.aspx7id=EW0._ KW. TEGOFIB}t_1kSBIBMG noSJuG3XinZ0_yJUMO 1 QUEFROUABTZBXMVIARF co822, 240 PM HEALTH CARE QUALIFIED DEPENDENT ENROLLMENT FORM Policy Year Nov. 15, 2021 - Nov. 14, 2022 23. Your FREE Dependent's Marital Status * SINGLE v 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? * No v 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 25.1 confirm that after filling out this form, | will submit the applicable supporting document(s). Yes This content is created by the owner of the form. The data you submit will be sent to the form owner, Microsoft is not responsible for the privacy or security practices ofits customers, including those of this form owner. Never give ‘out your password. hitps:forms.office.com/Pages/ResponsePage.aspx7id=EW. KW. 7IEGOFIB_1KSBIBMG1n05JuG3XinZO_yJUMO1QUEFROUABTZBXMVIARF... 7/88/22, 240 PM HEALTH CARE QUALIFIED DEPENDENT ENROLLMENT FORM Policy Year Nov. 15, 2021 - Nov. 14, 2022 Powered by Microsoft Forms | The owner of this form has not provided a privacy statement as to how they will use your response data. Do not provide personal or sensitive information, | Terms o hitps:forms.offce.com/Pages/ResponsePage.aspx7id=EW. KW. 7IEGOFIB}_1KSBIBMG1no5JuG3XinZO_yJUMO!QUEFROUABTZBXMVIARF... 8/8