DEPENDENTs' HMO ENROLLMENT FORM

For the Policy Period: 2022 - 2023

EMPLOYEE NAME: EMPLOYEE NO.: BIRTH DATE: (mm/dd/yyyy)

CIVIL STATUS: DATE APPLIED: COMPANY / PLANT: DEPARTMENT:

NAME OF DEPENDENT RELATIONSHIP BIRTH DATE (mm/dd/yyyy) AGE (as of 31 March 2022) CIVIL STATUS GENDER
1.

2.

3.

4.

5.

GUIDELINES
Employee's Civil Dependent Eligibility Requirements
Status (displayed based on enrollment (for new / additional dependents only)
hierarchy)
I. PARENTS Not SMC employed Birth Certificate of Employee and Parent/s
SINGLE II. BROTHERS / Only if both Parents are deceased, siblings 15 days old up to 23 years old; single, unemployed, and Death Certificate of both Parents
SISTERS totally and financially dependent to the employee. Enrollment must be from eldest to youngest.
I. PARENTS Not SMC employed Birth Certificate of Employee and Parent/s
SINGLE PARENT II. BROTHERS / Only if both Parents are deceased, siblings 15 days old up to 23 years old; single, unemployed, and Death Certificate of both Parents
[Employee may only choose ONCE: SISTERS totally and financially dependent to the employee. Enrollment must be from eldest to youngest.
either Parents (/Siblings) OR
Children] I. CHILDREN Legitimate, illegitimate or legally adopted; 15 days old up to 23 years old; single, unemployed, and Birth Certificate or Legal Adoption Papers of
totally and financially dependent to the employee. Enrollment must be from eldest to youngest. Children
MARRIED / WIDOWED I. SPOUSE Legitimate and not SMC employed Marriage Contract
/ LEGALLY II. CHILDREN Legitimate, illegitimate or legally adopted; 15 days old up to 23 years old; single, unemployed, and Birth Certificate or Legal Adoption Papers of
SEPARATED totally and financially dependent to the employee. Enrollment must be from eldest to youngest. Children
NOTES:
*Open to all REGULAR employees.
*NO AUTOMATIC RENEWAL. Existing members must apply for annual renewal.
*HIERARCHY shall be STRICTLY followed. All declarations made in this form shall be deemed correct and will be subject to verification and approval.
*Qualified dependents must be enrolled at the start of the policy period.
*Enrollment must be made within 30 days from eligibility period.
*Newly born child may be enrolled within 30 days from the 15th day from date of birth (i.e. 45 days from date of birth).
*Only the ff. may be enrolled in the middle of the policy period: spouse of newly married employee, newly born child, and dependent/s of newly hired / regularized employee.
*Cancellation in the middle of the policy period will not be allowed unless valid and acceptable.
DEPENDENT'S REGISTRATION
I understand that this insurance will be issued based on the above statements which I represent are true and complete to the best of my knowledge. I authorize any physician, hospital, clinic, or any medically-
related facility to furnish COCOLIFE information leading to my dependents' medical history and physical condition. I hereby agree that if there be any misinterpretation in the above statements, COCOLIFE
shall have the right to reject and declare such insurance null and void.
AUTHORITY TO DEDUCT WAIVER ON NON-REGISTRATION
This is to authorize the Company to deduct from my payroll my share on the HMO premium cost
amounting to PHP _________________ / month. My total annual premium contribution is PHP I understand further that my voluntary act of not registering my dependents to SMC-accredited HMO
________________. would mean the following:
HMO PREMIUM (Employee Share) • that I observe and correctly follow the hierarchy of enrollment;
• that all my unenrolled dependents are no longer covered by SMC's Health Plan and/or HMO Plan for
AGE GROUP MONTHLY PREMIUM PER DEPENDENT
employee dependent;
15 days to 70 years old PHP 478.00
• that beyond the deadline set for registration to HMO, I cannot enroll any of my dependents anytime
71 to 80 years old PHP 955.00 during the policy period;
81 to 90 years old PHP 1,432.00 • that I take full responsibility for my dependent's medical needs including hospitalization.
91 to 93 years old PHP 3,338.00
DATA PRIVACY CONSENT STATEMENT
San Miguel Corporation and its subsidiaries ("SMC") shall collect and process Personal and Sensitive Personal Information (collectively "Personal Data") for the purpose of enrollment to HMO. SMC may
disclose your Personal Data to other processors, and observe the appropriate storage and disposal in accordance with the Records and Retention Policy of SMC. Please read in full the company Privacy
Policy found in the employee portal “My AccESS”.

By signing this form, I confirm that I have read, understood and agree to the processing of all Personal Data provided herein in accordance with the terms and conditions stated above as well with the Privacy
Policy of SMC. I also warrant that consents are obtained from individuals other than myself whose Personal Data are shared in relation to this enrollment.
CONFORME: I also do hereby acknowledge that I have read, fully understood and agree to abide by the guidelines set forth by SMC, AIBC and Cocolife in view of my dependents' HMO enrollment and
coverage. This document shall form part of my HMO policy. Any misinterpretation or non-disclosure of material facts will automatically render the policy null and void.
EMPLOYEE SIGNATURE: DATE: