Hospital Income Benefit Plan Enrollment Form

Hospital Income Benefit Plan

Accidents do happen, and by nature With Paramount’s Hospital Income Benefit
Monthly Premiums
I understand that this does not obligate me
in any way & that I will have the opportunity
Plan, we want to help you alleviate the stress
they happen when you least expect to inspect my policy for up to 10 days before 10-day
in medical bill payment so that you or your I accept it. I understand that the insurance
Plan 2000 free look
them to. But sometimes, our own loved one can get well secure in your insurance Pays P 2,000 a day (P 60,000 a month) will take effect when my policy is issued and
Individual, I have paid my first premium during my guarantee
existing medical conditions challenge coverage. Age of
Policy Individual
Individual Spouse & lifetime and good health.
& Spouse All Children
our health. In these cases the battle Owner
Please Print (Full Name)
1. Daily Cash Benefit is provided for hospital 20-24 P 272.95 P 520.95 P 696.95
can be long and costly. At Paramount, confinements. 25-29 336.95 648.95 888.95 Mr. Mrs. Ms.
First Name M.I. Last Name
30-34 416.95 800.95 1,104.95
we understand that sometimes 35-39 520.95 992.95 1,336.95
2. Daily Cash Benefit is doubled for hospital Address
we must live with health concerns confinement due to dread disease. 40-44 640.95 1,224.95 1,592.95
45-49 784.95 1,496.95 1,864.95
throughout our lives and that they 50-54 960.95 1,832.95 2,104.95
Zip Code Tel. No.
3. Convalescence Benefit provides a lump sum Mobile No. Nationality
need attention too. payment for prolonged hospitalization of 30
55-59
60-64
1,168.95
1,408.95
2,224.95
2,680.95
2,448.95
2,864.95 TIN, SSS, GSIS
days or more. Date of Birth Place of Birth
The Hospital Income Benefit plan
4. The Daily Cash Benefit is paid starting on day Plan 3000 Pays P 3,000 a day (P 90,000 a month)
Occupation Age Female Male
E-mail
is a hospitalization plan for clients aged 20 to 64 one. There is no exclusion period. Age of
Individual
Individual,
Policy Individual Spouse & Buss. Address
years old. Coverage and payment periods last up Owner & Spouse All Children
to age 70. This provides fixed cash benefits based 5. Cash Benefits are paid directly to you. Zip Code Office Tel. No.
20-24 P 408.95 P 780.95 P 1,044.95
on the plan chosen at the time of enrollment. 6. Hospital confinements associated with pre- 25-29 504.95 972.95 1,332.95 Indicate the persons to be insured
Yourself Yourself and your Spouse Family
30-34 624.95 1,200.95 1,656.95
existing conditions are covered after two
About the Plan years of the policy’s date of effectivity.
35-39 780.95 1,488.95 2,004.95 Please check the plan you require:
Plan 1000 Plan 2000 Plan 3000 Plan 4000
40-44 960.95 1,836.95 2,388.95

45-49 1,176.95 2,224.95 2,796.95
Whether the result of an accident or illness, Fill out if you wish to enroll your family:
7. Special Waiver of Premium Benefit. 50-54 1,440.95 2,748.95 3,156.95 Name Age Birthday
the medical care that you or a family member 55-59 1,752.95 3,336.95 3,672.95 Spouse
might need may include medicines, hospital 8. Protects your whole family for one low 60-64 2,112.95 4,020.95 4,296.95 Children
confinement and recovery assistance. All these monthly premium. aged
3 months
medical needs add up and can become very
expensive. 9. Gives you the choice of four plans: Plan 1000, Plan 4000 Pays P 4,000 a day (P 120,000 a month) to
20 years old
Plan 2000, Plan 3000 and Plan 4000. Age of Individual,
Policy Individual Spouse &
*Use separate sheet if necessary.
Individual & Spouse
Owner All Children Applicant’s
10. Plus - Inflation Benefit. All your benefits 20-24 P 544.95 P 1,040.95 P 1,392.95 Signature
Date

increase by 20% over the next 2 years at no 25-29 672.95 1,296.95 1,776.95 Credit Card Authorization (If paying via credit card only)
extra cost. 30-34 832.95 1,600.95 2,208.95 I authorize Paramount Life to charge my premiums to my credit card.
35-39 1,040.95 1,984.95 2,672.95 American Express Diners
40-44 1,280.95 2,448.95 3,184.95
Pre-existing Conditions 45-49 1,568.95 2,992.95 3,728.95 Any Visa or Mastercard JCB

To keep premiums low, no benefit shall be provided, during

50-54 1,920.95 3,664.95 4,208.95 Cardholder’s Name
the first two years, for Hospital Confinement resulting to an 55-59 2,336.95 4,448.95 4,896.95 Card Number Amount
Injury, Sickness, any Dread Disease or Pre-Existing Condition 60-64 2,816.95 5,360.95 5,728.95 Tel./ Mobile No. Expiry Date
for which you or a Covered Family Member have received *For Plan 1000 premiums, feel free to call our office.
I hereby understand and agree that should my Credit Card be refused by the Credit
treatment or advice for treatment or medication prior to the Card Company for whatever reason, failing to meet my financial obligation, this
Effective Date or date of last reinstatement of the policy. A premium payment arrangement shall be immediately revoked/cancelled even without
Pre-Existing Condition is defined as any Injury or Sickness or Premiums are based on the age of the policyholder (if single) or prior notice to me. I further agree that Paramount Life shall not be held liable in case
of termination of the Policy as a result of such revocation/cancellation.
any covered Dread Disease which have been diagnosed or the elder spouse at the time the policy is issued. All dependent
have required medical treatment prior to the Effective Date or children from 90 days to 20 years of age are included in the Cardholder’s Date
date of last reistatement of this policy. Family coverage. Children’s benefits are 50% of parents’ benefits. Signature
Hospital Income Benefit Plan Hospital Income Benefit Plan
No Stamp Needed
Permit No. 1495-A
BUSINESS REPLY

Enroll in 3 easy steps:

1. Look at the chart to determine the monthly
premium according to the plan desired.
2. Complete the Enrollment Form. Be sure all
questions are answered.
3. Sign and date the Enrollment Form.
Remember, you should be the one to sign
the form.
Health Protection

AT A GLANCE:
• A hospitalization insurance plan for clients Hospital Income
Benefit Plan
Business Reply Envelope

20-64 years old.

Paramount Life & General
Insurance Corporation

• Types of coverage: Individual, Joint, and

Postage will be paid by

Attention: Direct Marketing

Family.
Makati CPO BOX 2526
1265 Makati City

• Benefits include: Daily Cash, Dread disease,

Convalescence Benefits and coverage for
Pre-existing Conditions.

Detach and fold the completed form and mail it to:

Paramount Life & General Insurance Corporation

11th Floor Sage House, 110 V.A. Rufino Street,

Legaspi Village, Makati City 1229, Philippines
Telefax: +632 772 9264

A division of:

www.paramountdirect.com