HMO ENROLLMENT FORM

Coverage Period: November 4, 2022 – November 3, 2023

PART I: EMPLOYEE PERSONAL INFORMATION

LAST NAME FIRST NAME MI

C U B I L L A S L U I S A J E N N A C

EMPLOYEE CIVIL STATUS GENDER CONTACT NUMBER EMAIL ADDRESS

NUMBER MARRIED F 09204879752 [email protected]
254254

PART II: TERMS AND CONDITIONS FOR ENROLLMENT

A. Only REGULAR INGRAM MICRO associates are eligible to enroll dependents

B. Plan Hierarchy and Eligible Dependents
C. Philhealth Membership
 All Enrollees and dependents must be Members of Philhealth. Please refer to
Philhealth’s membership eligibility.
 In case a member failed to file his Philhealth benefits, the Philhealth portion of the
hospital bill must be paid directly by the Maxicare member to the hospital.
D. Enrollment SLA
 For newly regularized associates, enrollment of dependents will only be allowed
within 14 calendar days from the date of regularization.
 For newly married associates who wish to enroll their spouse, enrollment of
dependents must be within 30 days from the date of marriage.
 For associates with newborn, enrollment of newborn must be within 30 days from
the date of birth.
 Once enrollment has been done, cancellation will not be allowed.
E. Applicable Premiums and deductions
 Premiums for voluntary dependent/s of newly regularized, newly married associate
and newly born dependent shall be computed on a pro-rated basis and deductions
will start on the nearest payout until the last payout of October of the following
year.

PART III: LIST OF DEPENDENTS (Maximum of 5 Dependents including Company Paid Dependent;
Classification shall be based on hierarchy)

1. LAST NAME FIRST NAME MI

C U B I L L A S R I C K Y E

PHILHEALTH # CIVIL SEX (M/F) DATE OF BIRTH (MM/DD/YYYY) RELATIONSHIP TO

18-201020397-0 STATUS M 07/10/1993 THE ASSOCIATE
MARRIED HUSBAND

2. LAST NAME FIRST NAME MI

C U B I L L A S X A V I E R J A C O B C

PHILHEALTH # CIVIL SEX (M/F) DATE OF BIRTH (MM/DD/YYYY) RELATIONSHIP TO

N/A STATUS M 04/20/2017 THE ASSOCIATE
SINGLE SON
3. LAST NAME FIRST NAME MI

PHILHEALTH # CIVIL STATUS SEX (M/F) DATE OF BIRTH (MM/DD/YYYY) RELATIONSHIP TO

THE ASSOCIATE

4. LAST NAME FIRST NAME MI

PHILHEALTH # CIVIL STATUS SEX (M/F) DATE OF BIRTH (MM/DD/YYYY) RELATIONSHIP TO

THE ASSOCIATE

5. LAST NAME FIRST NAME MI

PHILHEALTH # CIVIL STATUS SEX (M/F) DATE OF BIRTH (MM/DD/YYYY) RELATIONSHIP TO

THE ASSOCIATE

PART IV: CERTIFICATION, DATA PRIVACY AND AUTHORITY TO DEDUCT

I hereby certify that I have read and understood the terms and conditions for all declared dependents that
will be enrolled under Ingram Micro’s HMO Program.

 Plan Hierarchy and Classification

 Applicable Premiums and Deductions
 Service Level Agreements
 Philhealth Membership
 Inclusions and Exclusions of the HMO Plan

All information contained in this application form are true and complete to the best of my knowledge, and
that any misrepresentation as to material fact indicated herein shall be a cause for the
cancellation/discontinuance of HMO coverage.

*Rates reflected above are inclusive of 12% VAT.

I hereby authorize Ingram Micro to deduct the pro-rated premiums of my dependents. Premiums for
voluntary dependent/s of newly regularized, newly married associate and newly born dependent shall be
computed on a pro-rated basis and deductions will start on the nearest payout until the last payout of
October 2022. For any correction on the deduction, notification shall be sent thru email and will be
automatically deducted from the nearest payout. I also understand that separation of employment from
Ingram Micro will mean discontinuance of my HMO coverage as well as my dependents. I acknowledge
that any unpaid outstanding balance will be automatically deducted from my final remuneration.
In addition, In reference to my and/or my dependent/s’ healthcare plan procured by the Company, I
hereby certify that I and my dependent/s have read and understood the Summary of Coverage and
Benefits of the Service Agreement executed by Maxicare Healthcare Corporation (“Maxicare”) and the
Company including all procedures, benefits, exclusions, limitations and conditions contained therein, and
agree to be bound thereby. Furthermore, by availing the services of Maxicare, I and my dependent/s
acknowledge and agree to abide by all the membership terms and conditions published via Maxicare
website at https://maxicare.ph/member-terms.

In executing this document and in affixing my signature hereto, I confirm that:

1. I agree and understand that in the course of providing service/s to me or my dependents, Maxicare
shall engage the services of, and/or interact with, other third parties, such as, but not limited to its
parent company, affiliated companies, subsidiaries, financial advisors, affiliated third parties or
independent/non-affiliated third parties and service providers, whether local or foreign (collectively
referred to as "Representatives").
2. I and my dependent/s have freely, knowingly and voluntarily given my consent for Maxicare and its
Representatives to:
a. Obtain, collect, examine, process, and store copies of my and/or my dependents’ personal
information, including sensitive personal information, privileged information, medical
records or any other information relative to my (and/or my dependents’) hospitalization,
consultation, treatment or any medical advice in connection with the benefit/claim availed
under the Agreement as may be deemed necessary by Maxicare. Except as otherwise stated
hereon, any information obtained relative to the authority herein given shall be strictly
confidential. The extent of the collection and processing shall be necessary and incidental to
the performance of the services contemplated in the Agreement.
b. Disclose such information to the Company, its representatives, agents and brokers, Maxicare
and its Representatives, including the service providers which will perform the services
contemplated in the Agreement, for any legitimate business purpose as Maxicare may deem
appropriate, including but not limited to outsourced processing of Maxicare transactions,
profiling or historical statistical analysis, providing advice or information which Maxicare and
its Representatives believe may be of interest to me or the Company, to effectively
administer or manage my account, enhance customer services, or to communicate with me
or the Company for any purpose.
Processing is hereby understood to include any operation or any set of operations performed upon
personal information including, but not limited to, the collection, recording, organization, storage,
updating or modification, retrieval, consultation, use, consolidation, blocking, erasure or destruction of
data. Processing would include both manual and automated handling of personal information and storage
and data transfers using various means including but not limited to physical methods as well as electronic
via information and communications systems employed by Maxicare and its Representatives.
3. I have been duly authorized by my dependent/s to sign and execute any and all documents and make
representations for and in his/their behalf as if the same were personally done by him/them.
4. I hereby warrant that we understand our rights and obligations pursuant to the Data Privacy Act and
its implementing rules and regulations. I and my dependents understand that we retain the right to
be informed, to object, access, complain, and rectify, to request for filtering of certain information,
and to the corresponding damages in case of violation of our rights within the corresponding
limitations as set forth in the pertinent laws.
5. I and my dependents hereby represent that, in order to provide the services contemplated in the
Agreement, the authorities herein provided shall be valid and existing during the term of the
Agreement, including any extensions thereof, and until necessary for the establishment, exercise or
defense of any claims arising from the said Agreement.
6. I and my dependents hereby agree to hold Maxicare and its Representatives free and harmless from
and against any and all suits or claims, actions, or proceedings, damages, costs and expenses,
including attorney’s fees, which may be filed, charged or adjudged against Maxicare or any of its
directors, stockholders, officers, employees, agents, or Representatives in connection with or arising
from the use, processing and disclosure by Maxicare or its Representatives of the aforementioned
information pursuant to Maxicare’s reliance on my and my dependent’s representation and warranty
that Maxicare, the Company, and their representatives have the authority to examine, use, process,
store, share, or disclose, as the case may be, said information for the above-mentioned purposes.
7. Maxicare reserves the right to amend the Membership Terms and Conditions at any time without
need of prior notice or approval, and any queries related thereto may be addressed to
[email protected].

Lastly, I hereby authorize Ingram Micro to deduct the applicable HMO premiums based on my enrollment.
For any correction on the deduction, notification shall be sent thru email and will be automatically
deducted from the nearest payout. I also understand that separation of employment from Ingram Micro
will mean discontinuance of my HMO coverage as well as my dependents. I acknowledge that any unpaid
outstanding balance will be automatically deducted from my final remuneration.
________ Luisa Jenna C. Cubillas___________ ______3/31/2023________
SIGNATURE OVER PRINTED NAME DATE

For further inquiries, please email Manila HR Services at [email protected]