MEMBER APPLICATION DATA

CONTRACT NO:

34F The Orient Square, Emerald Ave.,

Ortigas Center, Pasig City, Philippines
www.medicareplusinc.com

APPLICATION FOR HEALTH COVERAGE X INDIVIDUAL FAMILY

NAME OF THE APPLICANT
CAMA JASON EGLESIA

LAST NAME FIRST NAME MIDDLE NAME

ADDRESS 312 QUARRY BRGY MINUYAN PROEPR CITY OF SAN JOSE DEL MONTE BULACAN BULACAN 3023
BLK / LOT NO. STREET / BRGY MUNICIPALITY PROVINCE / REGION ZIP CODE
TELEPHONE NO.: MOBILE NO.: 0905-043-8713 EMAIL ADDRESS: gennaalob1990@gmail.com
MEMBER'S DATA

BIRTHDAY (MM/DD/YYY): 03/27/1990 AGE: 34 GENDER: FEMALE / MALE

PLACE OF BIRTH: QUEZON CITY HEIGHT: 5’6 WEIGHT: 82

NATIONALITY: FILIPINO ARE YOU A US CITIZEN?

IF YES, PLEASE FILL OUT THE CONSENT & AUTHORIZATION FOR US PERSONS UNDER US FATCA AND W9 FORMS.
CIVIL STATUS: / SINGLE MARRIED ANNULLED
122201777 212001465926 34-3200977-3
TIN NO: PHILHEALTH NO. SSS NO. / GSIS NO.
SOURCE OF FUNDS: ALLOTMENT: BUSINESS: / SALARY: COMMISSION: DONATIONS:
NAME OF EMPLOYER / BUSINESS: LOCAL GOVERNMENT UNIT

NATURE OF WORK: BARANGAY OFFICIALS OCCUPATION: BARANGAY KAGAWAD

NAME OF PAYOR (IF PRINCIPAL APPLICANT IS BELOW 18 YEARS OLD)

PAYOR'S DATA

LAST NAME FIRST NAME MIDDLE NAME RELATIONSHIP TO THE PRINCIPAL

RELATIONSHIP TO
NAME OF DEPENDENTS BIRTHDATE AGE GENDER NATIONALITY MEMBERSHIP PLAN
PRINCIPAL
DEPENDENT'S DATA

NECITA CAMA 04’04/1956 68 FEMALE FILIPINO MOTHER

MIRA CLAIRE A. CAMA 10/31/2020 3 FEMALE FILIPINO DAUGHTER

PLAN TYPE: X INDIVIDUAL FAMILY PLAN

ROOM & BOARD: WARD (MAX OF 1,000) SEMI PRIVATE (MAX OF 2,000) X PRIVATE (MAX OF 3,000)
DENTAL: X COVERED NOT COVERED
PRE-EXISTING: NOT COVERED X COVERED 10%
PLAN DATA

LIMIT: 60,000.00 80,000.00 100,000.00 110,000.00 120,000.00

200,000.00 MBL X ABL
COVERAGE:
X ACCESS TO ALL ACCREDITED HOSPITALS, CLINICS AND DIAGNOSTICS CENTERS X 24/7 HEALTH ASSISTANCE HOTLINE

X EMERGENCY BENEFITS X OUT - PATIENT BENEFITS X IN - PATIENT BENEFITS X ANNUAL PHYSICAL EXAM
X DENTAL COVERAGE X COVID ILLNESS COVERAGE PLAN X 1 YEAR CONTRACT VALIDITY

ADDITIONAL BENEFIT:
HEALTHY MIND SOLUTIONS - ACCESS TO AN ONLINE MENTAL WELLNESS PLATFORM (ANNUAL PAYMENT ONLY)

PAYMENT DETAILS:
TCP: 12,600 PREMIUM FEE:

PAYMENT DATE:
TERMS: ANNUAL

MODE OF PAYMENT

BANK DEPOSIT CREDIT CARD CHEQUE PAYMENT GCASH CASH

Note: Each applicant under Family Plan must fill up the Application for Health Coverage for Family Plan Form.

Please check the () appropriate box in answering the questions below, use the last page of this form for details of YES answers.

YES NO YES NO
4. Other than the above, have you: Had any physical or any
1. Have you ever had a history of treatment, consultation of known indication of
known indication thereof?

a. Had a medical examination, consultation,

a. Disorder of the eyes, nose, or throat?
illness, or injury or surgery?

b. Dizziness, fainting, convulsions, headache, speech b. Been a patient in a hospital, clinic,

defect, paralysis or stroke, mental or nervous disorders? sanitarium or any other clinic facility?

c. Shortness of breath, persistent hoarseness or cough,

c. Had Electrocardiogram, Xray or any other
blood spitting, tuberculosis, asthma, or other chronic
diagnostic tests?
respiratory disorders.

d. Chest pain, palpitation, high blood pressure, rheumatic

d. Been advised to have any diagnostic
fever, heart murmur, heart attack, or other disorder of
tests, hospitalization or surgery
the heart or blood vessels?

e. Jaundice, intestinal bleeding, ulcer, hernia,

appendicitis, colitis diverticulitis, hemorrhoids, recurrent
e. Which was not completed?
indigestion, or other disorder of the stomach, intestine,
liver, or gall bladder?

f. Sugar, albumin, blood or pus in the urine, venereal 5. Have you had any military service
disease, stone, or other disorder of kidney, bladder, determent, rejection, or discharge because
prostate, or reproductive organs of a physical or mental condition?

g. Diabetes, thyroid, or other endocrine disorder? 6. Do you have a parent, brother or sister
who died of or had high blood pressure,
h. Neuritis, sciatica, rheumatism, arthritis, gout, or tuberculosis, diabetes, cancer, heart or
disorder of the muscles or bones, such as the spine, kidney disease or mental illness? if so, what
back, or joints age?

7. Do you or other members of the family

i. Deformity, lameness, or amputation?
smoke?
j. Disorder of the skin, lymph glands, cysts, tumor, or a. If yes, since when? How many sticks a
cancer? day?

b. How long you've been smoking? How

k. Allergies, anemia, or other disorder of the blood
many sticks a day?

l. Excessive use of alcohol, tobacco, or any habit-forming c. Have you stopped smoking? Since
drugs? when?

2. Are you presently under observation or taking

8. FOR FEMALES ONLY
treatment?

a. Have you ever had any abnormal

menstruation, pregnancy, childbirth or disorder
3. Have you had any substantial changes in weight in the of the female organ or breast?
past years?
b. Are you pregnant now? If yes, how many
months?

DETAILS OF THE YES ANSWERS TO THE HEALTH QUESTIONNAIRE

DATE OF HISTORY OF TREATMENT OR
CHIEF COMPLAINTS AND / OR DIAGNOSIS TREATMENT AND RESULTS
CONFINEMENT
WHAT ARE THE LIMITATIONS OF YOUR HEALTH PLAN?
Medicare Plus has certain limitations which are necessary in order to maintain high-quality medical services at affordable
membership fees for our members.

1. Non-coverage of Pre-existing Conditions

An Illness, Injury or condition shall be considered pre-existing if it existed before the Effective Date of theMember's coverage,the
natural history of which can be medically determined to have started prior to the effective date of coverage or at the time of
processing of the Member's application, whether or not the Member was aware of such Illness, Injury or condition.

Pre-existing illness before application date shall be subject to exclusion of coverage

For purposes of this provision, it is hereby understood and agreed that the following Illnesses, Injuries or conditions, butnot to the
exclusion of all others including their complications and sequelae, when occuring during the first year of coverage after the Effective
date or reinstatement date shall be considered Pre-existing: (1) Asthma/Chronic Obstructive Lung disease;(2) Buergher's disease; (3)
Calculi of the urinary system; (4) Cataract/Glaucoma; (5) Cerebrovascular Accident Transient/ Ischemic Attack; (6) Cholecystitis; (7)
Cirrhosis of the liver; (8) Collagen disease; (9) Diabetes Mellitus; (10) Diseased tonsils and sinus conditions requiring surgery; (11)
Endometriosis/ Myoma/Ovarian Cyst; (12) ENT conditions requiring surgery (13) Epilepsy/Sezure disoder; (14) Fatty liver; (15)
Gastric or Duodenal ulcer; (16) Goiter and other thyroid disorders; (17) Hallux valgus; (18) Hemorrhoids/Anal Fistula; (19)
Hernia/Benign Prostatic Hypertrophy; (20) Hypertension and other Cardiovascular diseases; (21) Migraine; (22)
Osteoarthritis/Gout/Hyperuricemia; (23) Paralysis and other Neurological disorders; (24) Pathological Abnormalities of nasal
septum or turbinates; (25) Peptic ulcer disease; (26) Spinal column abnormalities; (27) Tuberculosis; (28) Tumor, whether benign
or malignant, of all organs and organ systems, including malignancies of the blood and bone marrow; (29) Varicose veins; (30) Any
dreaded disease.

Pre-existing Condition shall only be covered after one year from Effective Date of the Member's coverage, except for illness or
condition specifically excluded by an endorsement which is made part of the Healthcare Agreement, provided that there is no failure
to disclose, misrepresent or conceal, Material Information in the original Application or Application for Reactivation. Notwithstanding
the disclosure by the Member of a pre-existing condition, Medicare Plus may permanently exclude from cover or limit coverage a
specific medical condition, illness or injury upon written notice to the Member.

2. Room Assignment

You are entitled to a room accommodation corresponding to your type of plan. If you stay in a room classification higher than your
plan, you will have to pay not only for the excess in-room charges but also the excess in the professional fees and other hospital
ancillary charges. Please note that the fee charges for various procedures in the hospital, including professional fees, are based on
the type of patient’s room accommodation.

WHAT ARE YOUR RESPONSIBILITIES AS A MEDICARE PLUS MEMBER?

1. You must be up-to-date in the payment of your regular installment.

Your regular installment is payable under the mode of payment you have chosen. While Medicare Plus endeavors to remind you of
your regular installments due through a Statement of Account (SOA), there may be occasions when the SOA fails to reach your
address due to some uncontrollable factors. Payment of regular installment on time remains the responsibility of the Member. Non-
receipt of SOA or inability of respective Sales Associate to collect payments shall not serve as a ground to contest any decision of
Medicare Plus to deny benefit because the contract is no longer in force due to non-payment.

2. Read your Medicare Plus Healthcare Agreement

To understand your benefits, please read and understand your Healthcare Agreement when you receive it following the approval of
your application. If you wish to terminate the Agreement, submit written notice within fifteen (15) days from receipt of the
Agreement, Member must also surrender to Medicare Plus the lD Card and the Agreement within the same period so that Medicare
Plus can process the refund the Membership Fees paid. Failure to terminate this Agreement within the period set shall be
understood as an acceptance of all terms and conditions provided hereunder. Any availment of the Member within the 15-day period
shall also mean acceptance by Member of all the terms and conditions of the Agreement.

For any clarification, please call us at Telephone No. 63 9088860472 or email us at customerservice@medicareplus.com.ph.
 DATA PRIVACY
I agree and consent that to the extent required by law, Medicare Plus, Inc., may collect, use, and process my personal information contained in my healthcare
application form for any of the following purposes, by the Data Privacy Act of 2012 and Medicare Plus Data Privacy Policy:

a. to process my application;
b. to administer my contract and benefits;
c. to provide customer service and support;
d. to research and conduct data analytics to improve customer service; and
e. to inform me of the latest's updates, special offers, and event invites related to my contract and benefits.

I hereby declare that I knowingly, intelligently, voluntarily, and willingly sign this form and/or that I have full authority to sign on behalf of the member whom I
am representing and I acknowledge that I have certain rights and protections by the Republic Act 10173, also known as the Data Privacy A ct of 2012, and that I
can send an e-mail message to customerservice@medicareplus.com.ph to further be apprised of the said rights and protections.

REQUIRED DOCUMENT (PROOF OF IDENTIFICATION): Attach a clean copy of TIN, SSS, GSIS ID, Philippine Passport, Driver’s
ACKNOWLEDGEMENT
I have read and understood the content of the Application and the limitation of my coverage.

I agree that this accomplished and signed application form shall be the basis of the contract between the undersigned applicant and Medicare Plus, Inc. and shall
be deemed to be an integral part of the Healthcare Agreement to be issued upon the acceptance hereof by Medicare Plus, Inc.

I agree that no binding agreement is created by the mere signing of this application until it is accepted and approved by Medicare Plus, Inc.
That I hereby authorize any physician, hospital, clinic, HMO, institution or person or other organization that has any record of my/our health to furnish Medicare
Plus, Inc. and all information about my/our health and medical history and any hospitalization, advice, diagnosis, treatment, disease or ailment. I/We also
consent to personal Investigation. A photocopy of this authorization shall be valid as the original.

I declare that the statements and answers contained herein are full, complete, and true, and if found otherwise, I agree that the Health Agreement may be
invalidated.

Signed on this day of 20 .

Signature Over Printed Name of Principal Applicant
JASON E. CAMA

In case of minor applicants:

I sign this application form as Parent or Guardian and on behalf of the minor applicant

Signature over printed name How did you know about us Signature over Printed Name of Health Advisor

O.R DATE: O.R No.: Amount Paid:

Finance Officer: Validation Date:

You can pay for your health plan via any of our payment facilities. Reminders:
PAYMENT MUST BE SETTLED IMMEDIATELY. FOR CHEQUE PAYMENTS OUR MESSENGER WILL 1. Forward the signed contract to your
PICK UP YOUR PAYMENT ON THE SAME DAY. designated Account Manager
2. Fill out the Members Application Form
3. Check payments should be made payable to
Thru Bank Deposit For Non- Bank MEDICARE PLUS INC.
Cheque payee & Account Name: 4. For 2% EWT deductions, please provide a copy
of BIR Form 2307 together with your payment
For more information, visit our website
MEDICARE PLUS INC. https://medicareplusinc.com.ph
UNION BANK: 000-88-00-23-557 PAYMENT REF #:
SAF-

Kindly enlist here your preferred list of hospitals:

Disclaimer:
Please note that Medicare Plus does not guarantee that the hospital you have listed is or will be part of our accredited list of
providers. Your Medicare Plan Advisor will coordinate with you on the list of accredited providers.

You can search for accredited hospitals, clinics, or doctors at our Accredited providers’ Page. Please click the link below for
more info.:
https://medicareplusinc.com/accredited-providers/