PhilCare x HomeCredit: Dependent Enrollment Form

PhilCare x HomeCredit: Dependent Enrollment Form

PhilCare x HomeCredit: Dependent Enrollment Form
Reminders:

1. Fill out this form if HCPH borrower/loan owner will avail HMO for his/her dependents.

2. NO NEED to fill out this form if HMO is for the Borrower/Loan owner.

3. Ensure to submit this accomplished form SAME DAY of the loan sigining date . Otherwise, HMO enrollee will be the Borrower/Loan owner.
DATA PRIVACY CONSENT

By clicking the agree button, you are allowing PhilhealthCare, Inc. (PhilCare) to collect and process your declared personal information in accordance to the Data Privacy Act of 2012.

Kindly be advised that all information provided will be retained to (a) facilitate enrollment; and (b) allow the member to access his/her membership services and tools.

Rest assured that this information shall not be disclosed to third parties or processed for any other purpose.
I agree

Borrower's Information
Loan Sign Date*

MonthDayYear
Date
Loan Account Number (LAN)*
Dependent's Information
Dependent's Last Name*
Dependent's First Name*
Dependent's Middle Name*
Dependent's Suffix (if applicable)
Dependent's Birthdate*

MonthDayYear
Date
MaleFemale
SingleMarriedWidowedSeparated
Dependent's Mobile Number*
Dependent's Email Address*
Dependent's House Address*
Dependent's City/Province*
Legal Age (18 yrs old and above)Minor (17 yrs old and below)

Borrower's Last Name*
Borrower's First Name*
Borrower's Middle Name*
Borrower's Suffix (if Applicable)

Upload Supporting Documents

Note: If the dependent is already of legal age, please disregard this request and proceed to the next page
The parent or legal guardian has an existing HMO plan, with corresponding proof of coverageThe parent or legal guardian is deceased, incapacitated, or otherwise unavailable, with corresponding legal proofThe parent or legal guardian is working abroad, with corresponding proof of employmentThe parent or legal guardian is overage or beyond the age eligibility of the benefit coverage
Please upload the applicable supporting documents (not more than 10MB)*

Cancelof
I hereby certify that all information provided are correct to the best of my knowledge and I fully understand the contents of the said form.

I take full responsibility for any false declaration and should there be any cost related modification, I understand that this would be to my account
I agree
Should be Empty: