Scribd
Upload
72 views1 page

COMPANY NAME: - Regular Salaried Employees - 18 To 65 Years Old

The document is an application form for regular salaried employees between 18-65 years old to enroll in health insurance with Caritas Health Shield. It requests information such as name, birthdate, age, gender, PhilHealth and SSS numbers, insurance beneficiary, pre-designated dependent. The applicant authorizes Caritas Health Shield to gather, process, use, share, store and dispose their personal and sensitive information for purposes of the health coverage application and otherwise. The applicant declares their answers are true or the health care agreement may be invalidated.

Uploaded by

Cart Sunrise Aguillon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
72 views1 page

COMPANY NAME: - Regular Salaried Employees - 18 To 65 Years Old

The document is an application form for regular salaried employees between 18-65 years old to enroll in health insurance with Caritas Health Shield. It requests information such as name, birthdate, age, gender, PhilHealth and SSS numbers, insurance beneficiary, pre-designated dependent. The applicant authorizes Caritas Health Shield to gather, process, use, share, store and dispose their personal and sensitive information for purposes of the health coverage application and otherwise. The applicant declares their answers are true or the health care agreement may be invalidated.

Uploaded by

Cart Sunrise Aguillon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 1

COMPANY NAME: _____________________________________________________________________________________

REGULAR SALARIED EMPLOYEES - 18 TO 65 YEARS OLD

Please fill out completely.

Name: ________________________________________________________________________________
Birth Date: __________________________________________ Age: ________ Gender: ___________
PhilHealth No.: ______________________________________ SSS No.: __________________________ 2 x 2 PICTURE
Insurance Beneficiary: __________________________________________________________________
WHITE BACKGROUND
Relationship to Beneficiary : _________________________ Birth Date: ________________________
(1st degree only)

Pre-Designated Dependent: ________________________ Birth Date: ________________________


4 Free Out-patient (Consult only)

“I hereby authorize any person, organization, or entity that has any record or knowledge of my health and/or that of my qualified
dependents (if any) to give to Caritas Health Shield any and all information concerning my hospitalization, consultation or
treatment in the course of my membership with Caritas Health Shield. I also authorize Caritas Health Shield to gather, process,
use, share, store and dispose my personal and sensitive information and/or that my dependents (if any). This authorization is in
connection with the application for healthcare coverage with Caritas Health Shield and for other purposes. This authorization
shall continue to be valid unless revoked in writing. A photographic copy of this authorization shall be as valid as the original.”

____________________________________________ ____________________________ ____________________


Employee Signature over Printed Name Designation Date

Name: ________________________________________________________________________________
Birth Date: __________________________________________ Age: ________ Gender: ___________
PhilHealth No.: ______________________________________ SSS No.: __________________________ 2 x 2 PICTURE
Insurance Beneficiary: __________________________________________________________________
WHITE BACKGROUND
Relationship to Beneficiary : _________________________ Birth Date: ________________________
(1st degree only)

Pre-Designated Dependent: ________________________ Birth Date: ________________________


4 Free Out-patient (Consult only)

“I hereby authorize any person, organization, or entity that has any record or knowledge of my health and/or that of my qualified
dependents (if any) to give to Caritas Health Shield any and all information concerning my hospitalization, consultation or
treatment in the course of my membership with Caritas Health Shield. I also authorize Caritas Health Shield to gather, process,
use, share, store and dispose my personal and sensitive information and/or that my dependents (if any). This authorization is in
connection with the application for healthcare coverage with Caritas Health Shield and for other purposes. This authorization
shall continue to be valid unless revoked in writing. A photographic copy of this authorization shall be as valid as the original.”

____________________________________________ ____________________________ ____________________


Employee Signature over Printed Name Designation Date

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

_______________________________________________________ ____________________________
Signature of Authorized Signatory over Printed Name Designation

You might also like