GOLDEN ARCHES DEVELOPMENT CORPORATION FORM #1-B CY 2020-2021 HMO Enrollment/ Update

for RESTAURANT MANAGEMENT TEAM

HMO ENROLLMENT & UPDATE FORM FOR PRINCIPAL & DEPENDENT/S and AUTHORITY TO DEDUCT FORM
(2020 - 2021 Contract Year)
SECTION I: EMPLOYEE / PRINCIPAL’S DATA (Please PRINT information completely and write LEGIBLY.)
Last Name First Name M.I. Employee Number

Position CSD (mm-dd-yyyy) Restaurant # Restaurant Name Contact #/ Mobile # (for verification purposes)

Sex Civil Status Date of Birth (mm-dd-yyyy) Email Address:

{Select} {Select}
Please state if you have an IMMEDIATE RELATIVE employed with GADC:

Name: _________________________________________ Relationship: ______________________ Dept/ Resto Name: ___________________________

SECTION II: PRINCIPAL PLAN PACKAGES & RATES
PLEASE CHECK ONE [ ] PLAN A [ ] PLAN B [ ] PLAN C [ ] PLAN D [ ] PLAN E [ ] PLAN F [ ] PLAN G [ ] PLAN H [ ] PLAN I [ ] PLAN J [ ] PLAN K [ ] PLAN L
Regular Open Regular Open Regular Open Regular Open Regular Open Regular Open
Room Type
Private Private Private Private Private Private Private Private Private Private Private Private
Maximum Benefit Limit P150,000 P150,000 P200,000 P200,000 P250,000 P250,000 P300,000 P300,000 P400,000 P400,000 P500,000 P500,000

ANNUAL PREMIUM 15,685.77 16,507.25 18,010.31 18,478.83 20,334.84 20,706.93 22,562.94 24,243.67 27,019.13 27,308.40 31,475.32 31,957.46
PREMIUM
ONE-TIME UPGRADE
COST
COST (For Salary 821.48 2,324.54 2,793.06 4,649.07 5,021.16 6,877.17 8,557.90 11,333.36 11,622.63 15,789.55 16,271.69
COVERED
Deduction)
BY GADC

SECTION III: DEPENDENT/S DATA (Please observe Enrollment Hierarchy):

IMPORTANT NOTE: 1. CANCELLATION IS NOT ALLOWED in the middle of the year unless there is a new coverage under a different HMO, living or working abroad, or deceased;
2. ALL DEPENDENT PARENTS & LEGAL SPOUSE, 71 to 75 y/o, enrolled after MARCH 1, 2017 will have 20% load on their HMO premium;
3. ALL DEPENDENT PARENTS & LEGAL SPOUSE, 76-77 y/o (existing & new) will have 50% load on their HMO premium.
Reason for skipping enrollment hierarchy (submit any
Birth Date Relationship to
Last Name, First Name, M.I. Gender
(mm-dd-yyyy)
documentation to validate your reason e.g. photocopy of other
Employee HMO card, employment contract overseas, death certificate)
1.
2.
3.
4.
5.
6.

SECTION IV: DEPENDENT/S PLAN PACKAGES & RATES (Computation based on Annual Premium)
PLEASE CHECK ONE [ ] PLAN A [ ] PLAN B [ ] PLAN C [ ] PLAN D [ ] PLAN E [ ] PLAN F [ ] PLAN G [ ] PLAN H [ ] PLAN I [ ] PLAN J [ ] PLAN K [ ] PLAN L
Regular Open Regular Open Regular Open Regular Open Regular Open Regular Open
Room and Board Plan
Private Private Private Private Private Private Private Private Private Private Private Private
Maximum Benefit Limit P150,000 P150,000 P200,000 P200,000 P250,000 P250,000 P300,000 P300,000 P400,000 P400,000 P500,000 P500,000
MONTHLY PAYMENT to GADC/ Deduction from Employee (from Mar 2020 to Feb 2021) based on Annual Premium
1 Dependent 1,591.17 1,663.49 2,024.38 2,086.56 2,457.60 2,580.48 2,643.27 2,775.44 3,014.62 3,165.35 3,385.97 3,555.27
2 Dependents 3,150.51 3,293.71 3,782.19 3,910.59 4,413.86 4,634.56 4,599.54 4,829.51 4,970.89 5,219.43 5,342.24 5,609.35
3 Dependents 4,528.30 4,734.13 5,335.33 5,522.25 6,142.36 6,449.48 6,328.04 6,644.44 6,699.39 7,034.36 7,070.74 7,424.27
4 Dependents 6,047.86 6,322.76 7,048.29 7,299.75 8,158.69 8,566.62 8,344.36 8,761.58 8,715.71 9,151.50 9,087.06 9,541.41
5 Dependents 7,607.04 7,952.82 8,805.92 9,123.59 10,004.89 10,505.14 10,190.57 10,700.10 10,561.92 11,090.01 10,933.27 11,479.93
6 Dependents 9,134.56 9,549.77 10,527.85 10,910.40 11,921.13 12,517.19 12,106.81 12,712.15 12,478.16 13,102.07 12,849.51 13,491.98
SECTION V. AUTHORITY TO DEDUCT NOTE
I hereby certify that all information provided herein, this application form and all supporting documents, are true and correct. I hereby confirm that I have read and understood
the 2020 - 2021 HMO Policies and Guidelines.
Should I or my qualified dependent/s become confined in a MEDICARD-accredited facility, the amounts not covered under the HMO Plan, including, but not limited to the excess
Room & Board, and disqualified expenses, shall be collected from me by the healthcare facility prior to discharge.
I understand that my dependents’ premium is my personal loan to Golden Arches Development Corporation (GADC) since it is on a nnual mode of payment and is paid in
advance by GADC to MEDICARD. I understand further that based on the HMO Policies and Guidelines, GADC applies the automatic renewal of dependents. For as long as I and
my dependent/s remain eligible and the Restaurant Support Center Clinic does not receive any cancellation form or plan upgrad e advice on the dates specified through email
notices, my dependent/s’ membership will be automatically renewed under existing plan coverage. I hereby authorize GADC to a utomatically renew my dependent/s’
coverage absent written advice from me of non-renewal within the period set by GADC.
I hereby authorize GADC to deduct from my monthly salary the HMO premiums for my dependent/s and any increase thereof in case of renewal. Also, should I upgrade my plan, I
hereby authorize GADC to deduct from my salary the additional premium cost. SHOULD I RESIGN OR BE TERMINATED FROM GADC, I AUTHORIZE GADC TO DEDUCT FROM MY FINAL
PAY THE REMAINING UNPAID PREMIUM BASED ON THE SECTION 11 OF THE 2020-2021 GADC HMO POLICIES & GUIDELINES.

Employee’s Signature: ___________________________________________ Date: _____________________________________

By providing your personal information and signature, you consent to the use, processing, storage, transfer and disclosure of your personal information for the purposes of processing and
availment of your HMO benefit and for payroll administration and reporting in accordance with the Data Privacy Act of 2012. Recipients of personal data that we collect include persons within
GADC HR and Legal Departments and Medicard Philippines (HMO Provider), in order to achieve the purposes mentioned. The personal information that we have collected will be properly stored
and filed within the HR Department and shall be retained for a period of five (5) years after the original purposes for which the personal information was collected have ceased to be applicable,
unless otherwise required by law or other mandatory directions by court or government authorities or for purposes of legal proceedings or other similar proceedings or investigations and will be
disposed of after the retention period.

Received by HR & Office Services: ________________________________ Date: _____________________________________