DEPENDENT'S ENROLLMENT FORM & SALARY DEDUCTION AUTHORIZATION FORM

DEPENDENT'S ENROLLMENT FORM & SALARY DEDUCTION AUTHORIZATION FORM

(HMO COVERAGE)
Name of Employee
Full Name
Position:
Department:
Civil Status
NEWRENEWAL

Dependent's Information:

Rows	Last Name	First Name	Middle Name	Birthdate mm/dd/year	Relationship (to the employee)
1
2
3
4
5
6
7
8

ELIGIBILITY (must follow Hierarchy)

For MARRIED EMPLOYEES:

1st Priority - Spouses not more than 65;

2nd Priority - Legitimate, legal adopted or legitimized children who are unmarried, unemployed, whplly dependent financially upon the member at least 30 days old and not more than 21 years old.

For SINGLE/SINGLE PARENT EMPLOYEES:

1st Priority - Biological children who are unmarried, unemployed, at least 30 days old and not more then 21;

2nd Piority - Parents not more than 65;

3rd Priority - Brother's, sisters at least 30 days old and not more the 21; only if wholly financially dependent upon the member.

This authorizes accounting/payroll to deduct from my salary the amount of __________________ (PHP _________________ )Avega annual fund as payment for any utilization earned of enrolled dependent\s. This deduction shall be made every 15th and 30th of the month starting August 15, 2024 . Any excess of dependent/s utilization will be shoulder by the employee.

Further, I hereby agree that in the event of separation, the company is authorized to deduct the total annual utilization balance of my enrolled dependent/s.
Amount of membership fee per dependents:
Amount of membership fee to be deducted per payday:
No. of dependent/s:
Total membership fee:

Classification	Maximum Benefit Limit	Membership FEE
Semi-Private	PHP 100,000.00	PHP 600 per member/year (subject to 12% VAT)
Payward	PHP 60,000.00	PHP 600 per member/year (subject to 12% VAT)

I understand that by signing this form, I voluntarily provide the abovementioned personal information, and I acknowledge and give my consent to the Company to use this information for AVEGA enrollment purpose.

Signature of Employee

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