Kaiser Membership Quotation Request Form

Membership Online Application Form

Fill out the form carefully for proper assistance
Your Full Name*

First NameFull Middle NameLast Name
Your E-mail*
kaiserintl@gmail.com
Occupation/Profession*
Your Current Work or Job
Birth Date*

YearMonthDay
Gender*
Male or Female
Mobile Number*
Civil Status*

SingleMarriedSeparatedWidowed
Nationality*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
TIN
Not Mandatory field (Leave it blank if forgotten or not available)
Nationality*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Height*
(ex. 5`6")
Weight*
in KG * 2.2 = lbs
Place of Birth*
Educational Attainment*

ElementaryHigh SchoolCollege
PHILIPPINE ADDRESS INFO*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer or Company Name
Country based of Employer or Company

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Port of Entry (if Seaman) or Destination Country (if OFW)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Known of any impairment in your health?*

YesNo
Been hospitalized and/or undergone surgery?*

YesNo
Have ever the habit of smoking cigarettes?*

YesNo
Do you engage in any hazardous sport or vacation, a Politician?*

YesNo
Are you a Philhealth Member?

YesNo
Your Facebook Profile Account Link
SAMPLE: https://www.facebook.com/AndrewFabillarJr/
Which HMO Plan are you interested in?

Short Term (Yearly Renewable Plan)Long Term (Kaiser 3 in 1 HMO Plan)Senior Care (For applicants age 61-100)
LTC Plan Type*
STC Plan Type*
Payment Term Options*
Dependents*
Assigned Beneficiaries

You can assign atleast one(1) up to four(4) beneficiaries. Leave blank if don't want to assign anyone.
Primary beneficiary*
Full name
Age*
Current Age
Relationship*
Spouse/Son/Daugther/Parent
2nd beneficiary
Full name
Age
Current Age
Relationship
Spouse/Son/Daugther/Parent
3rd beneficiary
Full name
Age
Current Age
Relationship
Spouse/Son/Daugther/Parent
4th beneficiary
Full name
Age
Current Age
Relationship
Spouse/Son/Daugther/Parent
Signature*

Clear
Should be Empty:

Membership Online Application Form

Assigned Beneficiaries