INTELLICARE APPLICATION FORM (FOR PRINCIPAL AND DEPENDENT)

PRINCIPAL APPLICANT (EMPLOYEE)

Check appropriate box
WILL AVAIL WILL NOT AVAIL

NAME _________________________________________ SEX______BIRTHDAY____________ CIVIL STATUS_______ DATE HIRED____________ POSITION______________ BRANCH__________

(Last Name) (First Name) (Middle Name)
DEPENDENT
PLAN
REMARKS (CHECK
CIVIL (write the plan DESIRED ACTION)
LAST NAME FIRST NAME MIDDLE NAME BIRTHDAY SEX RELATIONSHIP
STATUS you would want to avail for
your dependent) ADD DELETE

RATES (November 15, 2018 to November 14, 2019)

High light or encircle the plan you want to avail
PRINCIPAL MEMBER (NO ACCESS TO THE 6 MAJOR HOSPITALS: Makati Medical Center, St. Luke's Medical Center - QC, St. Luke's Medical Center - Global City, Cardinal Santos Medical
Center, Asian Hospital and Medical Center & The Medical City) & Healthway Clinics
PLAN TYPE ROOM AND BOARD MBL OLD RATES per QUARTER NEW RATES per QUATER
PLATINUM LARGE PRIVATE 300, 000 With Access to the 6 major 4,641.56 5,013.12
Hospitals
GOLD 1 REGULAR PRIVATE 200, 000 3,930.08 4,244.80
GOLD 2 SMALL PRIVATE 150, 000 3,634.40 3,925.60
SILVER SEMI PRIVATE 100, 000 2,812.88 3,038.56
BRONZE 1 WARD 80, 000 2,467.05 2,664.48

DEPENDENTS (NO ACCESS TO THE 6 MAJOR HOSPITALS: Makati Medical Center, St. Luke's Medical Center - QC, St. Luke's Medical Center - Global City, Cardinal Santos Medical Center,
Asian Hospital and Medical Center & The Medical City) & Healthway Clinics
PLAN TYPE ROOM AND BOARD MBL OLD RATES per QUARTER NEW RATES per QUATER
PLATINUM LARGE PRIVATE 300, 000 With Access to the 6 major 5,337.64 5,765.76
Hospitals
GOLD 1 REGULAR PRIVATE 200, 000 4,519.76 4,882.08
GOLD 2 SMALL PRIVATE 150, 000 4,179.84 4,514.72
SILVER SEMI PRIVATE 100, 000 3,234.56 3,494.40
BRONZE 1 WARD 80, 000 2,837.18 3,064.32

OVER AGE DEPENDENTS (66-70 years old) (NO ACCESS TO THE 6 MAJOR HOSPITALS: Makati Medical Center, St. Luke's Medical Center - QC, St. Luke's Medical Center - Global City,
Cardinal Santos Medical Center, Asian Hospital and Medical Center & The Medical City) & Healthway Clinics
PLAN TYPE ROOM AND BOARD MBL OLD RATES per QUARTER NEW RATES per QUATER
GOLD 1 REGULAR PRIVATE 200, 000 - With Access to 6 major Hosp. 9,039.52 9,763.04
BRONZE 1 WARD 80, 000 - Without Access to 6 major Hosp 5,910.80 6,384.00

NOTES:
1. Entitlement for an HMO will be based on the conditions indicated in the employees job offer sheet / package.
2. Employees who are not yet entitled for an HMO but wish to be covered may submit enrollment form; However, 100% of the premium cost will be charged to the employee's personal account through salary deduction
3. Employees who wish to upgrade their coverage may do so, provided that they will shoulder the difference in cost.
4. Employees who would like to enroll their dependents will shoulder the 100% of the premium cost. Packages for dependents may either be lower or equivalent to the principal member's package.
5. For new or additional dependents, copy of the birth certificate (NSO copy) and marriage contract (for married individuals) must be attached to this application form

I hereby certify that the above information are current and correct and that I am conforming to the conditions indicated above.
_________________________
Signature over printed name
Name Date Sent
Alterado, Lara Plynn 10/22/2019
Del Rosario 10/22/2019
Gavilan 1/16/2020
Quindara, Christine Joy 2/6/2020
Tidor, Donna Mae 2/6/2020
De Guzman, Jodi Anne 2/6/2020
Dichosa, Ma. Joji 2/6/2020
Soriano, Ainelyn 2/6/2020
Carlos, Mary Jeszylle A 2/6/2020