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
Format: (000) 000-0000.
Civil Status
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
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?
Been hospitalized and/or undergone surgery?
Have ever the habit of smoking cigarettes?
Do you engage in any hazardous sport or vacation, a Politician?
Are you a Philhealth Member?
Your Facebook Profile Account Link
SAMPLE: https://www.facebook.com/AndrewFabillarJr/
Which HMO Plan are you interested in?
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
Should be Empty:

Membership Online Application Form

Assigned Beneficiaries