Kaiser Membership Quotation
Fill out the form carefully for proper assistance
YOUR FULL NAME
*
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
E-mail
Confirmation Email
example@example.com
Philippines Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Current Work or Job
*
Your Current Work or Job
Birth Date
*
/
Day
/
Month
Year
Date
Place of Birth
*
Place of Birth:
*
Phone Number
*
-
Area Code
Phone Number
Gender
*
Male
Female
Civil Status
*
Single
Married
Separated
Widowed
Occupation/Profession
*
Your Current Work or Job
Nationality
*
Weight
*
in KG * 2.2 = lbs
Height
*
(ex. 5`6")
Educational Attainment
*
Elementary
High School
College
Employer or Company Name
*
Employer or Company Address INFO
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Port of Entry (if Seaman) or Destination Country (if OFW)
*
Country
Been hospitalized and/or undergone surgery?
*
Yes
No
Other
Known of any impairment in your health?
*
Yes
No
Have ever the habit of smoking cigarettes?
*
Yes
No
Do you engage in any hazardous sport or vacation, a Politician?
Yes
No
Are you a Philhealth Member?
*
TIN
*
KAISER BENEFICIARY
Primary
*
FULL NAME
RELATIONSHIP TO OWNER
AGE:
SECONDARY
*
FULL NAME
RELATIONSHIP TO OWNER
AGE:
THIRD
*
FULL NAME
RELATIONSHIP TO OWNER
AGE:
Fourth
*
FULL NAME
RELATIONSHIP TO OWNER
AGE:
ADDITIONAL QUESTIONS
ESTIMATED YOUR SALARY?
*
ANNUAL/ YEARLY
HUSBAND
First Name
Last Name
ESTIMATED YOUR SALARY?
ANNUAL/ YEARLY
LIVING WITH YOUR HUSBAND
Government ID
*
Browse Files
Cancel
of
Signature
*
Submit
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