AIA + MediCard Application Form
Apply for your HMO/Insurance plan. Choose your provider, plan, and payment mode.
Full Name
*
First Name
Last Name
Birthdate
*
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Month
-
Day
Year
Date
Contact Number
*
-
Area Code
Phone Number
Plan
*
Please Select
Basic Plan (₱899/mo) ANNUAL PAY ONLY
Standard Plan 🔥 Most Popular (₱2,500/mo)
Premium Plan (₱4,000/mo) with 1 dependent
Silver Plan (₱3,500/mo)
Gold Plan 🔥 Most Popular
(₱6,000/mo)with PRE-EXISTING CONDITIONS
Platinum Plan (₱8,000/mo) with PRE-EXISTING
all unused medicard plans will be refundable by the end of the coverage (get the highest you can afford)
Payment Mode
*
Please Select
Annual (10% Discount)
Semi-annual
Quarter
Monthly
credit card payment accepted (zero interest)
Monthly and Total Calculation
Secure your health & future today.
Submit
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