CORPORATE ENROLLMENT TEMPLATE (PRINCIPAL)

(*This excel file should be completely filled out by the authorized representative of the Client and submitted to Pacific Cross in case individual application form is not required.)

EMPLOYEES TO BE ENROLLED

Name of Beneficiary Relationship to

Occupation / Employee PhilHealth Birth Date of
Last Name First Name M.I. Gender Civil Status Nationality Birth Date Place of Birth Effective Date R&B / Plan MBL Address Email Mobile No. Landline No. Principal
Grade (Y/N) Beneficiary
Last Name First Name M.I. Applicant
Male 9/4/1986
Male 5/1/1987
Male 4/25/1985
Female 10/15/1996
Male 10/3/1997
Female 6/7/1996
Male 4/2/1997
Female 9/23/1988
Female 4/11/1993
Female 10/14/1997
Male 7/25/1997
Male 4/1/1987
Female 10/12/1992
Female 8/1/1998
Female 12/22/1996
Female 4/3/1998
Female 4/17/1998
Female 10/20/1995
Female 4/24/1996
Female 2/2/1985
Male 3/16/1999
Female 11/26/1999
Male 4/3/1996
Male 5/31/1995
Female 9/7/2000
Female 8/10/1996
Female 7/29/1999
Female 5/10/1998
Male 11/16/2000
Male 3/6/2001
Male 1/30/1999
Female 1/28/1999
Female 4/17/2000
Female 3/6/1996

LEGEND:
1 Last Name 11 R&B / Plan Suite, Private, Semi-Private, Ward
2 First Name 12 MBL Maximum Benefit Limit
PhilHealth
3 M.I. Middle Initial 13 (Y/N) Y - if with PhilHealth; N - if Non-PhilHealth
4 Gender M - Male, F - Female 14 Address Number, Street, Block, Subdivision, City, Zip Code, Province
5 Civil Status S - Single, M - Married, D - Divorced, W - Widow/Widower 15 Email Email address
6 Nationality Citizenship 16 Mobile No. 0xxx-xxxxxxx (mobile network prefix - number) or N/A
7 Birth Date mm/dd/yyyy 17 Landline No. 0xx-xxxxxxxx (area code - number) or N/A
8 Place of Birth Town/City and Province 18 Name of Beneficiary Last Name, First Name, M.I. (beneficiary under law of succession, Other necessary supporting documents)
9 Effective Date mm/dd/yyyy 19 Birth Date of Beneficiary mm/dd/yyyy
Relationship to Principal
10 Occupation / Employee Grade Exec./Mgr./Sup/R&F or as defined in the company 20 Applicant Spouse, Child, Sibling, Parent, Others

I HEREBY CERTIFY THAT THE ABOVE INFORMATION GIVEN ARE TRUE AND CORRECT. IN CASE ANY OF THE ABOVE INFORMATION IS FOUND TO BE FALSE OR MISREPRESENTING, PACIFIC CROSS HAS THE RIGHT TO IMMEDIATELY TERMINATE THE AGREEMENT

PREPARED BY:
SIGNATURE OVER PRINTED NAME DATE OF SIGNING PLACE OF SIGNING
AUTHORIZED REPRESENTATIVE

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CORPORATE ENROLLMENT TEMPLATE (DEPENDENTS)
(*This excel file should be completely filled out by the authorized representative of the Client and submitted to Pacific Cross in case individual application form is not required.)

DEPENDENTS TO BE ENROLLED

Place of Relationship to PhilHealth

Last Name First Name M.I. Gender Civil Status Nationality Birth Date Birth Effective Date Principal Principal (Employee) R&B / Plan MBL (Y/N) Address Email Mobile No. Landline No. Name of Beneficiary
Birth Date of Relationship to
Last Name First Name M.I. Beneficiary Dependent

LEGEND:
1 Last Name 12 R&B / Plan Suite, Private, Semi-Private, Ward
2 First Name 13 MBL Maximum Benefit Limit
PhilHealth
3 M.I. Middle Initial 14 (Y/N) Y - if with PhilHealth; N - if Non-PhilHealth
4 Gender M - Male, F - Female 15 Address Number, Street, Block, Subdivision, City, Zip Code, Province
5 Civil Status S - Single, M - Married, D - Divorced, W - Widow/Widower 16 Email Email address
6 Nationality Citizenship 17 Mobile No. 0xxx-xxxxxxx (mobile network prefix - number) or N/A
7 Birth Date mm/dd/yyyy 18 Landline No. 0xx-xxxxxxxx (area code - number) or N/A
8 Place of Birth Town/City and Province 19 Name of Beneficiary Last Name, First Name, M.I. (beneficiary under law of succession, Other necessary supporting documents)
9 Effective Date mm/dd/yyyy 20 Birth Date of Beneficiary mm/dd/yyyy
10 Relationship to Principal Spouse, Child, Sibling, Parent, Others 21 Relationship to Dependent Spouse, Child, Sibling, Parent, Others
11 Principal (Employee) Last Name, First Name, M.I. (Name of the principal payor of the dependent)

I HEREBY CERTIFY THAT THE ABOVE INFORMATION GIVEN ARE TRUE AND CORRECT. IN CASE ANY OF THE ABOVE INFORMATION IS FOUND TO BE FALSE OR MISREPRESENTING, PACIFIC CROSS HAS THE RIGHT TO IMMEDIATELY TERMINATE THE AGREEMENT

PREPARED BY:
SIGNATURE OVER PRINTED NAME DATE OF SIGNING PLACE OF SIGNING
AUTHORIZED REPRESENTATIVE

Here For You

CORPORATE ENROLLMENT TEMPLATE (EMPLOYEES and DEPENDENTS)
(*This excel file should be completely filled out by the authorized representative of the Client and submitted to Pacific Cross in case individual application form is not required.)

EMPLOYEES TO BE ENROLLED

Last Name First Name M.I. Gender Civil Nationality Birth Date Place of Birth Effective Date Occupation / Employee R&B / Plan MBL PhilHealth Address Email Mobile No. Landline No.
Name of Beneficiary Birth Date of Relationship to
Status Grade (Y/N) Beneficiary Principal Applicant
Last Name First Name M.I.

DEPENDENTS TO BE ENROLLED

Last Name First Name M.I. Gender Civil Nationality Birth Date Place of Birth Effective Date Relationship to Principal Principal (Employee) R&B / Plan MBL PhilHealth Address Email Mobile No. Landline No. Name of Beneficiary
Status (Y/N) Birth Date of Relationship to
Last Name First Name M.I. Beneficiary Dependent

LEGEND:

PhilHealth
1 Last Name 13 (Y/N) Y - if with PhilHealth; N - if Non-PhilHealth
2 First Name 14 Address Number, Street, Block, Subdivision, City, Zip Code, Province
3 M.I. Middle Initial 15 Email Email address
4 Gender M - Male, F - Female 16 Mobile No. 0xxx-xxxxxxx (mobile network prefix - number) or N/A
5 Civil Status S - Single, M - Married, D - Divorced, W - Widow/Widower 17 Landline No. 0xx-xxxxxxxx (area code - number) or N/A
6 Nationality Citizenship 18 Name of Beneficiary Last Name, First Name, M.I. (beneficiary under law of succession, Other necessary supporting documents)
7 Birth Date mm/dd/yyyy 19 Birth Date of Beneficiary mm/dd/yyyy

8 Place of Birth Town/City and Province 20 Relationship to Principal Applicant Spouse, Child, Sibling, Parent, Others
9 Effective Date mm/dd/yyyy 21* Principal (Employee) Last Name, First Name, M.I. (Name of the principal payor of the dependent)
10 Occupation / Employee Grade Exec./Mgr./Sup/R&F or as defined in the company 22* Relationship to Dependent Spouse, Child, Sibling, Parent, Others
11 R&B / Plan Suite, Private, Semi-Private, Ward
12 MBL Maximum Benefit Limit

I HEREBY CERTIFY THAT THE ABOVE INFORMATION GIVEN ARE TRUE AND CORRECT. IN CASE ANY OF THE ABOVE INFORMATION IS FOUND TO BE FALSE OR MISREPRESENTING, PACIFIC CROSS HAS THE RIGHT TO IMMEDIATELY TERMINATE THE AGREEMENT

PREPARED BY:
SIGNATURE OVER PRINTED NAME DATE OF SIGNING PLACE OF SIGNING
AUTHORIZED REPRESENTATIVE

Here For You

CORPORATE ENROLLMENT TEMPLATE (EMPLOYEES and DEPENDENTS)
(*This excel file should be completely filled out by the authorized representative of the Client and submitted to Pacific Cross in case individual application form is not required.)

EMPLOYEES TO BE DELETED

Name of Beneficiary Relationship to

Occupation / Employee PhilHealth Birth Date of
Last Name First Name M.I. Gender Civil Status Birth Date Effective Date R&B / Plan MBL Address Email Mobile No. Landline No. Principal
Grade (Y/N) Beneficiary
Last Name First Name M.I. Applicant

DEPENDENTS TO BE DELETED

PhilHealth
Last Name First Name M.I. Gender Civil Status Birth Date Effective Date Relationship to Principal Principal (Employee) R&B / Plan MBL Address Email Mobile No. Landline No. Name of Beneficiary
(Y/N) Birth Date of Relationship to
Last Name First Name M.I. Beneficiary Dependent

LEGEND:

PhilHealth
1 Last Name 11 (Y/N) Y - if with PhilHealth; N - if Non-PhilHealth
2 First Name 12 Address Number, Street, Block, Subdivision, City, Zip Code, Province
3 M.I. Middle Initial 13 Email Email address
4 Gender M - Male, F - Female 14 Mobile No. 0xxx-xxxxxxx (mobile network prefix - number) or N/A
5 Civil Status S - Single, M - Married, D - Divorced, W - Widow/Widower 15 Landline No. 0xx-xxxxxxxx (area code - number) or N/A
6 Birth Date mm/dd/yyyy 16 Name of Beneficiary Last Name, First Name, M.I. (beneficiary under law of succession, Other necessary supporting documents)
7 Effective Date mm/dd/yyyy 17 Birth Date of Beneficiary mm/dd/yyyy
Relationship to Principal
8 Occupation / Employee Grade Exec./Mgr./Sup/R&F or as defined in the company 18 Applicant Spouse, Child, Sibling, Parent, Others
9 R&B / Plan Suite, Private, Semi-Private, Ward 19* Principal (Employee) Last Name, First Name, M.I. (Name of the principal payor of the dependent)
10 MBL Maximum Benefit Limit 20* Relationship to Dependent Spouse, Child, Sibling, Parent, Others

I HEREBY CERTIFY THAT THE ABOVE INFORMATION GIVEN ARE TRUE AND CORRECT. IN CASE ANY OF THE ABOVE INFORMATION IS FOUND TO BE FALSE OR MISREPRESENTING, PACIFIC CROSS HAS THE RIGHT TO IMMEDIATELY TERMINATE THE AGREEMENT

PREPARED BY:
SIGNATURE OVER PRINTED NAME DATE OF SIGNING PLACE OF SIGNING
AUTHORIZED REPRESENTATIVE

Here For You