DEPENDENT ENROLLMENT CONFIRMATION FORM

EMPLOYEE INFORMATION

Employee Name: MARC BILIE B. QUITZON Birth Date: 12/20/1994 Gender: Male

Employee ID: 5867132 Civil Status: Single Contact Number: None

DEPENDENT(S) INFORMATION

Dependent No. 1
Name: TRISTAN YVAN OCHOADA Name:
Birth Date: 02/02/2022 Age: 1 Birth Date: Age:
Relationship Child Gender: Male Relationship Gender:
: :

Dependents Room & Board Benefit Limit Premium

(w/ VAT)
TRISTAN YVAN OCHOADA Small Private (Open) 120,000.00 801.34

The rate above reflects the premium per dependent enrolled. Dependents can no longer be cancelled within the policy year once the enrollment is
confirmed, except for the following conditions: Employee resignation, Death of the dependent, Coverage of dependent with another HMO provider
(subject to approval); Dependent will work overseas. Valid supporting documents must be submitted together with the deletion request .