MEDICASH DENGUE INSURANCE APPLICATION FORM

MEDICASH DENGUE INSURANCE

Application Form
Welcome! Thank you for choosing MediCash Dengue Insurance for yourself or your loved ones.

MediCash Dengue is a health insurance plan that provides a lump sum of ₱10,000.00 in medical cash assistance if the insured is diagnosed with dengue, even if hospitalization is not required.

This product is available for you, your family members, friends, and household staff, with ages 14 days old up to 70 years old - for only Php 350.00 for one year of coverage.

Please note: MediCash has a 15-day waiting period, meaning you can only claim benefits if the onset of dengue symptoms and your first doctor's consultation and diagnosis occur 15 days after your insurance coverage begins.

This product is underwritten by Pioneer Life, Inc. and distributed by InsuranceKo.

To activate your insurance plan, we need to collect the following personal information: Your Name, Date of Birth, Gender, Address, Email Address, and Contact Number.

By providing your personal information, you consent to the collection, use, and processing of your data as described below.

We will ensure that your information is handled with full confidentiality and privacy and will only be used for the purposes of activating your insurance and communicating with you regarding your policy as well as our products and services. You may view InsuranceKo's Data Privacy Policy here.

You have the right to access, correct, or request the deletion of your information. If you have any questions or concerns about your data, please contact us at dpo@insuranceko.ph.

Thank you for your trust in InsuranceKo!

Buyer's Details

Kindly provide your details.
Buyer's Name*

First NameLast Name
Buyer's Mobile Number
Please enter a valid mobile number.

Insured's Details

Please provide the details of the person to be insured (must be at least 14 days old and under 70 years of age).
Insured's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Current Date*

MonthDayYear
Date
Note: Age (Insured must be at least 14 days old and under 70 years of age)
Please enroll an eligible person for this insurance.
Gender*
Residence Address*

Full Address (Barangay, Municipality, Province/City)

Street Address Line 2

ProvinceState / Province

Postal / Zip Code
Email*
example@example.com
Mobile Number*
Please enter a valid mobile number.
Landline Number
Please enter a valid phone number.

You can pay your MediCash Dengue insurance premium of Php 350.00 (for one year of coverage) through GCash. Simply scan the QR code below and provide your payment reference or transaction details to complete your application.

If you prefer to pay using another method or have any questions about payment, please contact InsuranceKo at 0917-622-3964 anytime.

You will receive an email confirmation once your application has been successfully submitted.
Mode of Payment*

GCash Scan to PayI prefer to pay via other method or channel
Please provide your GCash transaction reference number.*
If you prefer to pay through another method or have any questions regarding payment, please contact InsuranceKo at 0917-622-3964 anytime.

Lastly, kindly provide the name or referrer ID of the InsuranceKo employee or associate who referred this product to you (if applicable).
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MEDICASH DENGUE INSURANCE

Buyer's Details

Insured's Details