Kaiser Membership Application

Kaiser Membership Application

Fill out the form carefully for proper assistance
Full Name*

First NameFull Middle NameLast Name
Your E-mail*
example@example.com
Confirm Your E-mail*
example@example.com
Mobile Number*

09Phone Number
Occupation/Profession*
Your Current Work or Job
Birth Date*

MonthDayYear
Gender?*

MaleFemaleN/A
Mobile Number*

Area CodePhone Number
Civil Status*

SingleMarriedSeparatedWidowed
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*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Educational Attainment*

ElementaryHigh SchoolCollegeOther
PHILIPPINE ADDRESS INFO *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer or Company Name*
Employer or Company Address INFO*

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
Philhealth Number*
Your Facebook Profile Account Link*
SAMPLE: https://www.facebook.com/mentorjered
I want to apply Kaiser Long Tern Care*

Long Term Care (Kaiser 3 in 1 HMO Plan)
Short Term Plan Type*
Long Term Plan Type*
Mode of Payment*
Name of Dependents/age/relationship

Ex. Juan Dela Cruz/18/son
Name of Dependents/age/relationship
Name of Dependents/age/relationship
Name of Dependents/age/relationship
Name of Dependents/age/relationship
Signature*

Clear
If you have questions, Send a message directly to my Facebook messenger.
Should be Empty:

Kaiser Membership Application

Name of Dependents/age/relationship