TECHLOG CENTER PHILIPPINES
MAXICARE - HMO ENROLLMENT FORM
IMPORTANT REMINDERS:
Enrollment of Dependents: Purpose (Check one):
- should be within 30 days from date of Principal's effectivity For New Enrollment For Updating
- must strictly follow hierarchy rule (child, parents,siblings*eldest to youngest*) (spouse,child*eldest to youngest*)
- must submit supporting documents (birth certificate of employee, birth certificate of newly born child, birth certificate of those with different surname,
marriage certificate of newly married,death certificate of deceased parents, photocopy of existing HMO card of deps to skip hierarchy , etc)
PRINCIPAL MEMBER'S INFORMATION
NAME: LAST NAME FIRST NAME MIDDLE NAME EXT. NAME
DATE OF BIRTH (mm-dd-yy) DATE HIRED: GENDER CIVIL STATUS
Male Single Widow(er)
Female Single-Parent Legally Separated
POSITION/JOB TITLE: _____________________ Married
FOR NEW ENROLLMENT (list dependents who are for enrollment only)
NAME OF 3 IMMEDIATE DEPENDENTS (premium to be paid by TCP)
LAST NAME FIRST NAME MIDDLE NAME EXT. NAME DATE OF BIRTH CIVIL STATUS GENDER RELATIONSHIP
AUTHORITY TO DEDUCT
To HR/PAYROLL:
I hereby authorize Techlog Center Philippines to deduct the HMO premium of the following additional dependent/s and/or extended or overaged dependent/s:
NAME OF IMMEDIATE DEPENDENTs in excess of the first 3 declared/enrolled dependents (Premium to be paid by the employee)
NAME OF OVERAGED IMMEDIATE DEPENDENT (Premium to be paid by employee)
LAST NAME FIRST NAME MIDDLE NAME EXT. NAME DATE OF BIRTH CIVIL STATUS GENDER RELATIONSHIP
NAME OF EXTENDED DEPENDENT (Premium to be paid by employee )
LAST NAME FIRST NAME MIDDLE NAME EXT. NAME DATE OF BIRTH CIVIL STATUS GENDER RELATIONSHIP
For an annual premium to a total of Php _______________ . Deduction amounts to PhP_______________ per pay period effective _______________.
I acknowledge that the premium for additional/extended dependents is not refundable and the coverage of dependents will cease upon deletion of employee & dependents
from the plan which may occur in case of absence without leave or separation from the company in the middle of HMO contract.
I understand that in the event of separation from the company during the current HMO policy period, any outstanding HMO premium due to Maxicare will be deducted from my
final pay or will be settled in cash in favor of TCP.
I also acknowledge that in the event of death of additional/extended dependent/s stated above in the middle of HMO contract, the full annual premium will be settled through
salary deduction.
I certify that above information are true and correct:
Employee's Signature over printed name Date
Employee's Contact No.
Processed by: Approved by:
Date : Date:
Asurion_Internal_Use_Only
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