HEALTH CARE PROGRAM
MEMBERSHIP APPLICATION
I hereby apply for membership of the Proposed Member below in the Health Care Program of Kaiser International Healthgroup, Inc.
(Kaiser) described herein subject to the Contract Provisions set forth in this Application. I agree that this Application and my declarations
and answers below, written by me or under my directions, shall be the basis, and deemed part of the contract between Kaiser and myself.
Proposed Member:
Last Name First Name Middle Name Height Weight
Date of Birth Age Place of Birth Nationality Gender: Civil Status
( ) Male ( ) Single ( ) Married
( ) Female ( ) Widowed ( ) Separated
Complete Home Address
Home Tel. No.:
Mobile No.:
Occupation (describe duties briefly) Employer Employer’s Address
TIN: Office Tel. No.: Port of Entry (if Seaman) Are you a Philhealth Member?
Destination Country (if OFW) ___ No
___ Yes, Philhealth No.: ____________
Owner / Payor (if the Proposed Member is 10-17 years old)
Last Name First Name Middle Name Height Weight
Date of Birth Age Place of Birth Nationality Gender: Civil Status
( ) Male ( ) Single ( ) Married
( ) Female ( ) Widowed ( ) Separated
Complete Home Address
Home Tel. No.:
Mobile No.:
Occupation (describe duties briefly) Employer Employer’s Address
TIN: Office Tel. No.: Port of Entry (if Seaman) Are you a Philhealth Member?
Destination Country (if OFW) ___ No
___ Yes, Philhealth No.: ____________
Beneficiary/ies Age Relationship to Owner Beneficiary/ies Age Relationship to Owner
1 3
2 4
Plan Data:
PLAN NAME: KAISER PREMIUM HEALTH BUILDER ULTIMATE KAISER HEALTH BUILDER
CORE PLAN RIDER PLAN
K-35 K-45 K-50 K-55 K-60 K-75 K-100 K-125 K-150 K-175 K-200 K-225
For K-250 above please indicate plan type: ________________
Mode of Payment: Spot Cash Annual Semi Annual Quarterly Monthly
First Payment Php: PR / SATR NO. Contract Price Php: Installment Php: Payment Form:
Cash Check Card Others
Revised Date: June 2014 Application No: 80001-
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Ground Floor King’s Court I Building, 2129 Chino Roces Avenue, Makati City
Telephone Nos.: (02) 892-9634 to 36 Fax No.: (02) 811-1878 Website: www.kaiserhealthgroup.com Page 1 of 4
Answer all the question pertaining to the Proposed Member or Owner/Payor (if the Proposed Member is 10-17 years old) by checking the appropraite box:
1. Have you ever: YesNo 5. Have you ever been rejected for insurance / health care plans
a. Availed of any medical / surgical consultation or treatment? or offered insurance at higher premiums?
b. Known of any impairment in your health? a. Ever had any application for insurance or reinstatement of
c. Been hospitalized and / or undergone surgery? reinsurance, declined, postponed or modified in amount, plan
d. Tested positive for antibodies to AIDS/hepatitis? or
e. Had, or sought consultation for, or been tested or treated for, rate with us or any other company?
or told to have AIDS or HIV infection if yes, what company? ______________________________
f. Been advised to have any diagnostic test, hospitalization or b. Any pending application for life, accident or health insurance
with us or any other company? If yes, what company?
surgery which was not completed?
6. Do you have undergoing medical treatment or observation
g. In the past 3 months, ever had continuous and unexplained or regular medication?
symptoms of fatigue, weight loss (how much? _____________),
a. In the past 5 years, had any consultation, medical advice,
diarrhea, enlarged lymph nodes, or unusual skin lesions? diagnostic test, treatment, accident, illness, operation not
2. Have you ever had the habit of smoking cigarettes? mentioned above?
If yes, how many per day?_________________________ (For WOMEN only)
a. Stopped smoking in the last 5 years? Why? _________ 7. Are you pregnant? If yes, how many months?___
b. Ever taken any habit-forming substance or drugs, alcoholic a.Date of last delivery: (Month)____(Day)_____(Year) ____
drinks in excess or had the abuse or treatment for smoking Abortion, miscarriage, abnormal labor / pregnancy?
habit or other addiction? Details: __________________________________________
3. Do you engage in any hazardous sport or vocation? b. Have you ever had any disease of the breast or female
organs or complications of childbirth?
a. Been active in politics, as a candidate or in any other
c.Have you ever had a papsmear that was abnormal
capacity during the last five years? or that had to be repeated?
4. Are you presently covered by any hospitalization or d. Have you ever had any family member who suffered from
medical plan? cancer of the breast?
a. Have you applied for or received a pension, payment or If yes, pleas give relationship/s and age of onset?
benefit due to injury, sickness or disability?
8. Do you have a history of any of the following: (if yes, check the box)
Asthma Convulsion (epilepsy) Single/multiple organ failure Hyperthyroidism / goiter
Tumors or internal organs Prostate problems Craniotomy Sinus requiring surgery
Hemorrhoids & Anal Fistulae Varicose veins Cancer Gastric or doudenal ulcer
Tuberculosis Hernia (acuired) Endometriosis Buerger's disease
Stone in urinary tract Diabetes mellitus Diseased tonsils Arthritis & bone disease
Hypertension Liver disease Gall bladder stone Benign new growths
Ear, nose, throat tumors Collagen disease Kidney/urological desease Cerebrovascular accident
Cataracts, Glaucoma Injuries from accident/assault Cardiovascular diseases Central nervous system lesions
Malignancies & blood dyscrasias Spinal stenosis
If you answered “YES” to any of the questionaire, please give details:
Name & address of personal Physician : _______________________________________________________
Date of last consultation : _______________________________________________________
Reason of last consultation : _______________________________________________________
Treatment given / medication prescribed : _______________________________________________________
Medication being taken : _______________________________________________________
Date
(AUTHORIZATION TO FURNISH MEDICAL INFORMATION) _________________________
I hereby authorize and request you, or any person, organization or entity that has any record or knowledge of the health and/or that of,
________________________________________ to give to Kaiser International Healthgroup, Inc. any and all information that the Company
may desire and which is relative to any consulation, treatment or any other medical advice or examination I/we had. A photostat (or similar
copy) of this authorization shall be as valid as the original. This information is in connection with my application for life insurance only.
___________________________________________________
Signature Over Printed Name of Legal Guardian/Owner or Payor Signature Over Printed Name of Proposed Member
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I hereby apply for insurance, as specified in the Health Care Program, and I agree that the said insurance coverage is based on the truth of
operations and health declarations stated herein and is subject to the provisions of the Group Master Insurance Policy issued by the
Insurance Company/ies. I___________________________________________________
hereby represent and declare to the best of my knowledge that I have not been confined on any hospital,
sanitarium of infirmary nor received medical or Signature Name of in
surgical treatment Proposed Member
the last twelve (12) months; that I have never been treated for heart
or Owner
condition, high blood pressure, cancer,/ Payor (if lung,
diabetes, the Proposed Member
kidney or stomach is 10-17
disorder years
or any old)
other physical or mental impairment in the last five
(5) years and that I am in good health and physical/mental condition.
__________________________________
Signature of Applicant or Payor
I hereby apply for Health Care Program with “NO INSURANCE BENEFIT” (NIB) __________________________________
Signature of Applicant or Payor
I declare that the statements and answers contained herein are full, complete and true, and if found otherwise, I agree that the Health Care
Agreement may be validated. I hereby authorize any person or entiry having a record or knowledge of my health to give Kaiser all information relative to
hospitalization medical treatment or consultation that I may have undergone.
I agree that no binding agreement is created byPlease
mere signing of thisyour
confirm application
emailuntil
add:it is accepted and approved by Kaiser International Healthgroup,
Inc. containing the Contract Provisions signed by the duly authorized officials of
___________________________________________________ Kaiser International Healthgroup, Inc. is issued to me. I am aware that I
will receive my policy via online, thru my email.
IN WITNESS THEREOF, I have signed this Application this _____________ day of _____________________, 20 ______________ in
______________________________(city / province where Applicant purchased the Kaiser Plan).
___________________________________________________ ___________________________________________________
Printed Name of Proposed Member Signature of Proposed Member
or Owner / Payor (if the Proposed Member is 10-17 years old) or Owner / Payor (if the Proposed Member is 10-17 years old)
Email address:
Confirm Email address
Note: Failure to provide email address may delay the approval of policy.
Witnessed by:
_______________________________________ _______________________________________
Signature of Sales Counselor Signature of Sales Counselor
_______________________________________ _______________________________________
Printed Name Printed Name
Agency Unit Associate’s Code Agency Unit Associate’s Code
For Kaiser Office use only:
________________________ _________________________
Processor's Name / Signature Date
Please see at the back for the Agent's Confidential Report Page 3 of 4
CONFIDENTIAL REPORT OF AGENT
IMPORTANT:
Please go over entire application carefully and review the answer to each question. Unanswered or incompletely answered question will result in delay by the Home
Office in taking final action on the application. Help the Proposed Member or Owner/Payor and Company by careful, complete and accurate preparation of the
application. The answers given by the Proposed Member or Owner/Payor form part of the insurance contract. Be specific, do not use indefinite terms (such as just met,
new contract, amply, etc.) Be sure to indicate what premium has been quoted (Question 7).
NOTE: If the Proposed Member is assisted by a legally authorized guardian, such guardian must sign his name and capacity below the signature of the ward.
1.a) How long have you known the Proposed Member or Owner/Payor? b) Are you related to the Proposed Member or Owner/Payor?
If yes, give relationship.
2. What is your estimate of Proposed Member or Owner/Payor's income?
3. Do you know of any information (habits, finances, marital status, involvement in legal cases, etc.) which might adversely affect the underwriting of this risk?
If yes, please explain.
4. a) If Proposed Member or Owner/Payor is married woman, e) Husband's Insurance in favor of Proposed Member or Owner/Payor
Husband's full name? ________________________________________________________
b) His occupation? ____________________________________________________________ Accident
Name of Insurance Company Year Issued Life Amount Amount
c) His Annual income? ________________________________________________________
d) Is Proposed Member or Owner/Payor living with her husband? _________
If not, why? __________________________________________________________________
5. If Proposed Member is below 18 years old. a) Are there any brothers or sisters who b) Insurance in force or applied for on life of brothers and sisters:
do not have any insurance if force or applied for? (if so, explain why insurance is not
being applied for now for them.) Insurance Year Issued /
Name Company Applied Amount
6. Does the appearance of the Proposed Member or Owner/Payor indicate good health? If not, please explain.
___________________________________________________________________________________________________________________________________________________________________________________
7. What premium was quoted to the applicant?
Life ________________________________________________________________ Total: Annual ______________________________________
Riders _____________________________________________________________ Semi-Annual ________________________________
_____________________________________________________________ Quarterly ____________________________________
_____________________________________________________________ Monthly _____________________________________
Policy Fee _________________________________________________________
ADDITIONAL OR EXPLANATORY REMARKS AND DETAILS TO ANSWERS QUESTION #1 TO 6 OF AGENT'S CONFIDENTIAL REPORT.
TO BE FILLED BY AGENT TO BE FILLED BY AUTHORIZED KAISER PERSONNEL
Non-Medical Authority: Application received and recorded by: C/A verified and confirmed by:
Date of Authority: Signature: Signature:
Signature: Date: Date:
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