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    HMO Dependents Employment & Upgrading Form

    Uploaded by

    Jim Kimberly Tilap
    This document is an HMO enrollment and upgrade form for employees of Mandaue Foam Industries. It contains sections for employee details, upgrading health plans, adding dependents, listing premium rates for different health plans and coverage levels, and obtaining approvals. Employees can choose to enroll dependents and upgrade their health plan. The form lists several plan options with different coverage limits and annual premium rates. It also provides for payment of premiums through cash or salary deduction. Key approvals from HR, payroll, and management are required as indicated at the bottom of the form.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    HMO Dependents Employment & Upgrading Form

    Uploaded by

    Jim Kimberly Tilap
    36 views2 pages
    This document is an HMO enrollment and upgrade form for employees of Mandaue Foam Industries. It contains sections for employee details, upgrading health plans, adding dependents, listing premium rates for different health plans and coverage levels, and obtaining approvals. Employees can choose to enroll dependents and upgrade their health plan. The form lists several plan options with different coverage limits and annual premium rates. It also provides for payment of premiums through cash or salary deduction. Key approvals from HR, payroll, and management are required as indicated at the bottom of the form.

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    This document is an HMO enrollment and upgrade form for employees of Mandaue Foam Industries. It contains sections for employee details, upgrading health plans, adding dependents, listing premium rates for different health plans and coverage levels, and obtaining approvals. Employees can choose to enroll dependents and upgrade their health plan. The form lists several plan options with different coverage limits and annual premium rates. It also provides for payment of premiums through cash or salary deduction. Key approvals from HR, payroll, and management are required as indicated at the bottom of the form.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    36 views2 pages

    HMO Dependents Employment & Upgrading Form

    Uploaded by

    Jim Kimberly Tilap
    This document is an HMO enrollment and upgrade form for employees of Mandaue Foam Industries. It contains sections for employee details, upgrading health plans, adding dependents, listing premium rates for different health plans and coverage levels, and obtaining approvals. Employees can choose to enroll dependents and upgrade their health plan. The form lists several plan options with different coverage limits and annual premium rates. It also provides for payment of premiums through cash or salary deduction. Key approvals from HR, payroll, and management are required as indicated at the bottom of the form.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    You are on page 1of 2

    MANDAUE FOAM Document Number : MFI-HRM-HSE04-007

    INDUSTRIES, INC. Effective Date : Dec 14, 2021


    Hernan Cortes St., Tipolo
    Mandaue City, Cebu 6014 Page : 1 of 2

    HMO DEPENDENTS ENROLLMENT AND UPGRADE FORM


    A. Employee Details
    Employee Number: Name: Position:

    Department: Employment Status: Date Hired:

    B. Employee Upgrade of Plan (Optional)


    Payward Reg. Private 120 Reg. Private 150 Suite
    _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No

    C. Dependent’s Information (Optional)


    Room With or
    Middle Date of Single or Relationship
    No. Last Name First Name Gender Category Without
    Initial Birth Married to Employee
    or Plan Dental
    1
    2
    3
    4
    5
    6

    ANNUAL MEMBERSHIP FEES:

    PRINCIPALS/ IMMEDIATE DEPENDENTS – PER PERSON


    ROOM & BOARD LIMITS PREMIUM VAT (12%) TOTAL PREMIUM WITH
    VAT
    Pay Ward 60,000.00 4,000.00 480.00 4,480.00
    Regular Private 120 120,000.00 8,025.00 963.00 8,988.00
    Regular Private 150 150,000.00 27,604.00 3,312.48 30,916.48
    Suite 200,000.00 38,934.00 4,672.08 43,606.08
    EXTENDED DEPENDENTS – PER PERSON
    ROOM & BOARD LIMITS PREMIUM VAT (12%) TOTAL PREMIUM WITH
    VAT
    Pay Ward 60,000.00 6,183.10 741.97 6,925.07
    Regular Private 120 120,000.00 12,438.75 1,492.65 13,931.40
    Regular Private 150 150,000.00 41,406.00 4,968.72 46,374.72

    D. Mode of Payment
    CASH SALARY DEDUCTION

    For Salary Deduction

    I hereby authorize MANDAUE FOAM INDUSTRIES, INC. to deduct from my payroll the total amount of ______________________________
    as payment of my plan upgrade or of my Dependent’s HMO premium.

    _________________________________
    Employee’s Signature over Printed Name

    E. Approval

    MARKRINELLO M. SARICAL CHRISTINE T. GIATORO RYAN ROBINSON U. UY


    HR MANAGER – GENERAL AFFAIRS PAYROLL SUPERVISOR MANAGING DIRECTOR

    Date: Date: Date:


    MANDAUE FOAM Document Number : MFI-HRM-HSE04-007

    INDUSTRIES, INC. Effective Date : Dec 14, 2021


    Hernan Cortes St., Tipolo
    Mandaue City, Cebu 6014 Page : 2 of 2

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