Академический Документы
Профессиональный Документы
Культура Документы
TO: Sole Proprietors, Small Enterprise Business Owners, Family Owned Business Proprietors, Start up
Businesses Owners, Franchise Owners,
As an industry forerunner, we pride ourselves of our more than 28 years of experience. With our strong financial muscle,
robust customer service and high caliber medical partners, we have turn to become the choice of the Top 2000
Corporations in the Philippines.
Companies with at least and only 5 employees can now enroll under Maxicares Corporate Program. Our options
and plan types have the following features:
Convenient Features
Easy requirements. No individual medical examination. No individual application forms, all applications are
considered approved
Access to more than 1000+ hospitals and clinics nationwide and 30,000 affiliated doctors
Access to Maxicares own Primary Care Centers located in major hospitals
Access to My Health Clinics
Optional Access to Top Major Hospitals (Asian Hospital & Medical Center, The Medical City, St. Luke's Medical
Center QC, St. Lukes Medical Center Global City, Makati Medical Center, Cardinal Santos Medical Center,
Cebu Doctors Hospital, Chong Hua Hospital & Davao Doctors Hospital)
Optional Access to Healthway Clinics
Customized and lower pricing for regional accounts (North Luzon, South Luzon, Visayas & Mindanao)
Coverage for Pre Existing Conditions subject to the package chosen:
1st Year 2nd Year onwards
Pre Existing Pre Existing Pre Existing Pre Existing
Access Size
Non Dreaded Dreaded Non Dreaded Dreaded
Conditions Conditions Conditions Conditions
5-9 Employees / Starter
Plan up to P5,000 up to P5,000 up to MBL up to P5,000
Nationwide 10-99 Employees /
Group Plan & 20-99 up to MBL
Employees / Small Plan
North Luzon
10-19 Employees / Platinum - Up to Php20,000; Gold up to MBL
Group Plan & 20-99 - Up to 15,000; Silver- Up to
South Luzon Employees / Small Plan 10,000; Bronze- Up to 5,000
Visayas
up to MBL
Mindanao
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
2
To proceed with the enrollment, kindly fill out the Maxicare Corporate Enrollment Sheet found at the last 3 pages
of our proposal and email those back to us. Kindly submit to us as well a copy of your BIR 2303 and company ID
of the contact person and signatory through email or fax at (02) 819-9899.
Note: The package attached is only applicable to companies with 5-99 employees. For companies with 100 employees
and up (or of the combined headcount of the employees and dependents exceeds 100), a separate proposal will be
drafted. Proposal is not applicable to accounts with previous experience with Maxicare. A separate proposal will be
drafted.
Should you have any other questions, you may call us at (02) 622-8892, (02) 215-1209 Mobile 09178046275,
09178046277 or email product.omg@gmail.com
Thank you.
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
3
TABLE OF CONTENTS
Introduction
Cover Letter 1-2
Nationwide Access Rates
5-9 Employees Starter Plan Rates with Nationwide Access 4
10-19 Employees Group Plan Rates with Nationwide Access 5-6
20-99 Employees Small Plan Rates with Nationwide Access 7-9
Optional Riders Rates for Nationwide Access 9
Provincial Access Rates
10-99 Employees Provincial Access Rates (North Luzon, South Luzon, Visayas & Mindanao) 10-13
Provincial Access Directory 13
Benefits & Limitations
Summary of Benefits 14-23
Rider Benefits Description & Inclusions 23-30
Exclusions and Limitations Provisions 31-32
Notes & Special Reminders 32-33
Pre Existing Non Dreaded & Dreaded Conditions 33-34
List of Providers
List of Hospitals & Clinics 34
List of Doctors 34
List of Dentists thru Dental Hub 34
List of ACU Annual Check Up Providers 34
Other Industries & Companies with 100 employees & up
Rated & Ineligible Industries 34-35
Ineligible Industries with less than 100 employees Requirements for Quotation 35
All Companies & Industries with 100 employees & up Requirements for Quotation 35-36
Enrollment Guidelines
Plan Types for Employees 36
Plan Types for Dependents 36-37
KYC Requirements for Employers 37-39
KYC Requirements for Employees 39
Enrollment Process Step by Step 39
Enrollment Form
Company Info Sheet 40
Employees' Masterlist 41
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
4
Dependents' Masterlist 42
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
5
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
6
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
7
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
8
Pharmaceuticals (Distributors), Sauna, Turkish bath, massage parlors (except spa, salons), Construction (Field Based or combined), Drillers (oil/water/gas), Firemen, Full Time athletes,
Government Institutions, Groups involving special hazards, Logging or Forestry, Manufacturers of Ammunitions, Medical Groups or any healthcare related, Mining / Underground mine
workers, NGOs, Foundations, Cooperatives, Associations, Oil production, Pharmaceutical (manufacturing), Political groups, Private households, Protection services (security guards)
** 9 Major Hospitals are: Asian Hospital & Medical Center, The Medical City, St. Luke's Medical Center QC, St. Lukes Medical Center Global City, Makati Medical Center, Cardinal Santos
Medical Center, Cebu Doctors Hospital, Chong Hua Hospital & Davao Doctors Hospital
***Healthway Clinics are located in Alabang Town Center, Edsa Shangri-la Mall, Festival Mall, Greenbelt 5, Market! Market!, Adriatico Tower Padre Faura & SM North
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
9
GOLD 2 Reg Pvt 150,000 22,298 12,041 6,243 29,424 15,889 8,239 23,410 12,641 6,555 30,894 16,683 8,650
GOLD 3 Reg Pvt 110,000 21,716 11,727 6,080 28,643 15,467 8,020 22,802 12,313 6,385 30,076 16,241 8,421
SILVER 1 Semi-Pvt 90,000 17,347 9,367 4,857 22,736 12,277 6,366 18,215 9,836 5,100 23,874 12,892 6,685
SILVER 2 Semi-Pvt 80,000 16,999 9,179 4,760 22,267 12,024 6,235 17,848 9,638 4,997 23,381 12,626 6,547
BRONZE Ward 70,000 14,036 7,579 3,930 18,266 9,864 5,114 14,740 7,960 4,127 19,177 10,356 5,370
*Rated Industries are Construction (office based), Education (except pre schools, tutorials & review centers), Law Firms, Media, Pharmaceuticals (Distributors), Sauna, Turkish bath,
massage parlors (except spa, salons)
** 9 Major Hospitals are: Asian Hospital & Medical Center, The Medical City, St. Luke's Medical Center QC, St. Lukes Medical Center Global City, Makati Medical Center, Cardinal Santos
Medical Center, Cebu Doctors Hospital, Chong Hua Hospital & Davao Doctors Hospital
***Healthway Clinics are located in Alabang Town Center, Edsa Shangri-la Mall, Festival Mall, Greenbelt 5, Market! Market!, Adriatico Tower Padre Faura & SM North
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
10
2017 PROVINCIAL NORTH LUZON (10-99 Employees) SOUTH LUZON (10-99 Employees)
PLAN
ROOM MBL STANDARD INDUSTRIES RATED INDUSTRIES STANDARD INDUSTRIES RATED INDUSTRIES
TYPES
EMPLOYEES Ann Semi Qtr Ann Semi Qtr Ann Semi Qtr Ann Semi Qtr
PLATINUM 1 Open Suite 500,000 21,565 11,645 6,03826,465 14,291 7,410 24,269 13,105 6,795 28,098 15,173 7,867
PLATINUM 2 Small Suite 350,000 13,685 7,390 3,83217,545 9,474 4,913 16,390 8,851 4,589 19,178 10,356 5,370
PLATINUM 3 Small Suite 250,000 13,124 7,087 3,67516,952 9,154 4,747 15,829 8,548 4,432 18,585 10,036 5,204
PLATINUM 4 Open Pvt 250,000 11,460 6,188 3,20914,803 7,994 4,145 13,819 7,462 3,869 16,227 8,763 4,544
PLATINUM 5 Open Pvt 200,000 11,140 6,016 3,11914,388 7,770 4,029 13,432 7,253 3,761 15,771 8,516 4,416
PLATINUM 6 Lrg Pvt 200,000 10,781 5,822 3,01913,924 7,519 3,899 13,000 7,020 3,640 15,265 8,243 4,274
GOLD 1 Reg Pvt 200,000 9,751 5,266 2,73012,593 6,800 3,526 11,759 6,350 3,293 13,805 7,455 3,865
GOLD 2 Reg Pvt 150,000 9,428 5,091 2,64012,177 6,576 3,410 11,369 6,139 3,183 13,349 7,208 3,738
GOLD 3 Reg Pvt 110,000 9,080 4,903 2,54211,727 6,333 3,284 10,949 5,912 3,066 12,857 6,943 3,600
SILVER 1 Semi-Pvt 90,000 7,408 4,000 2,074 9,568 5,167 2,679 8,933 4,824 2,501 10,488 5,664 2,937
SILVER 2 Semi-Pvt 80,000 7,198 3,887 2,015 9,298 5,021 2,603 8,679 4,687 2,430 10,191 5,503 2,853
BRONZE Ward 70,000 5,953 3,215 1,667 7,688 4,152 2,153 7,179 3,877 2,010 8,429 4,552 2,360
DEPENDENTS
PLATINUM 1 Open Suite 500,000 26,699 14,417 7,476 33,096 17,872 9,267 30,457 16,447 8,528 35,364 19,097 9,902
PLATINUM 2 Small Suite 350,000 18,820 10,163 5,270 24,176 13,055 6,769 22,577 12,192 6,322 26,444 14,280 7,404
PLATINUM 3 Small Suite 250,000 18,259 9,860 5,113 23,583 12,735 6,603 22,016 11,889 6,164 25,851 13,960 7,238
PLATINUM 4 Open Pvt 250,000 15,583 8,415 4,363 20,127 10,869 5,636 18,792 10,148 5,262 22,065 11,915 6,178
PLATINUM 5 Open Pvt 200,000 15,260 8,240 4,273 19,709 10,643 5,519 18,401 9,937 5,152 21,605 11,667 6,049
PLATINUM 6 Lrg Pvt 200,000 14,821 8,003 4,150 19,142 10,337 5,360 17,871 9,650 5,004 20,984 11,331 5,876
GOLD 1 Reg Pvt 200,000 13,352 7,210 3,739 17,247 9,313 4,829 16,100 8,694 4,508 18,905 10,209 5,293
GOLD 2 Reg Pvt 150,000 13,028 7,035 3,648 16,827 9,087 4,712 15,711 8,484 4,399 18,447 9,961 5,165
GOLD 3 Reg Pvt 110,000 12,681 6,848 3,551 16,380 8,845 4,586 15,294 8,259 4,282 17,957 9,697 5,028
SILVER 1 Semi-Pvt 90,000 10,070 5,438 2,820 13,006 7,023 3,642 12,144 6,558 3,400 14,259 7,700 3,993
SILVER 2 Semi-Pvt 80,000 9,862 5,325 2,761 12,738 6,879 3,567 11,890 6,421 3,329 13,962 7,539 3,909
BRONZE Ward 70,000 8,093 4,370 2,266 10,453 5,645 2,927 9,759 5,270 2,733 11,459 6,188 3,209
NO OPTIONAL RIDERS: Ann Semi Qtr Ann Semi Qtr
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
11
1 Standard Dental (1 prophylaxis and 2 Lightcure) 369 199 103 369 199 103
2 Annual Check-up (Basic 5) Clinic 1,334 720 374 1,877 1,014 526
3 Life AD&D (Php25,000) 51 28 14 51 28 14
4 Cancer Benefit (Php200,000) 448 242 125 448 242 125
5 Maternity Benefit 3,161 1,707 885 3,161 1,707 885
6 International Assistance 484 261 136 484 261 136
7 Wellness Program 4,516 2,439 1,264 4,516 2,439 1,264
8 Fee for Service for Senior Citizens P415 initial processing fee and then actual costs + 13.5% claims handlng fee
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
12
GOLD 1 Reg Pvt 200,000 12,915 6,974 3,616 15,164 8,189 4,246 12,915 6,974 3,616 15,964 8,621 4,470
GOLD 2 Reg Pvt 150,000 12,604 6,806 3,529 14,799 7,991 4,144 12,604 6,806 3,529 15,576 8,411 4,361
GOLD 3 Reg Pvt 110,000 12,269 6,625 3,435 14,406 7,779 4,034 12,269 6,625 3,435 15,163 8,188 4,246
SILVER 1 Semi-Pvt 90,000 9,741 5,260 2,727 11,439 6,177 3,203 9,741 5,260 2,727 12,040 6,502 3,371
SILVER 2 Semi-Pvt 80,000 9,541 5,152 2,671 11,204 6,050 3,137 9,541 5,152 2,671 11,794 6,369 3,302
BRONZE Ward 70,000 7,826 4,226 2,191 9,190 4,963 2,573 7,826 4,226 2,191 9,675 5,225 2,709
NO OPTIONAL RIDERS: Ann Semi Qtr Ann Semi Qtr
1 Standard Dental (1 prophylaxis and 2 Lightcure) 369 199 103 369 199 103
2 Annual Check-up (Basic 5) Clinic 1,166 630 326 1,166 630 326
3 Executive Check Up Outpatient Cebu Doctors Hospital 3,604 1,946 1,009 n/a n/a n/a
4 Executive Check Up Intpatient Cebu Doctors Hospital 31,495 17,007 8,819 n/a n/a n/a
5 Executive Check Up Intpatient Davao Doctors Hospital n/a n/a n/a 30,529 16,486 8,548
6 Life AD&D (Php25,000) 51 28 14 51 28 14
7 Cancer Benefit (Php200,000) 448 242 125 448 242 125
8 Maternity Benefit 3,161 1,707 885 3,161 1,707 885
9 International Assistance 484 261 136 484 261 136
10 Wellness Program 4,516 2,439 1,264 4,516 2,439 1,264
11 Fee for Service for Senior Citizens P415 initial processing fee and then actual costs + 13.5% claims handlng fee
*Standard Industries are companies whose nature of business are NOT Construction (office based), Education (except pre schools, tutorials & review centers), Law Firms, Media,
Pharmaceuticals (Distributors), Sauna, Turkish bath, massage parlors (except spa, salons), Construction (Field Based or combined), Drillers (oil/water/gas), Firemen, Full Time athletes,
Government Institutions, Groups involving special hazards, Logging or Forestry, Manufacturers of Ammunitions, Medical Groups or any healthcare related, Mining / Underground mine
workers, NGOs, Foundations, Cooperatives, Associations, Oil production, Pharmaceutical (manufacturing), Political groups, Private households, Protection services (security guards)
**Rated Industries are Construction (office based), Education (except pre schools, tutorials & review centers), Law Firms, Media, Pharmaceuticals (Distributors), Sauna, Turkish bath,
massage parlors (except spa, salons)
***Visayas access has access to Cebu Doctors Hospitals and Chong Hua Hospital
***Mindanao access has access to Davao Doctors Hospital
PROVINCIAL ACCESS
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
13
Note: Accounts requesting for Baguio access should enroll under our Nationwide Program
VISAYAS
Members may avail to any accredited hospital/clinics within Visayas regions only.
MINDANAO
Members may avail to any accredited hospital/clinics within Mindanao regions only.
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
14
B. IN-PATIENT CARE
1 Room and Board Accommodation Subject to the Member's Room and Board limit
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
15
Use of operating room, Intensive Care Unit
Subject to MBL
(ICU), isolation room (if prescribed by
2
attending Accredited Physician) and
recovery room.
Professional fees in accordance with
3
Maxicare Schedule of Rates.
a. Attending Physicians Subject to MBL
b. Surgeons Subject to MBL
c. Anesthesiologists Subject to MBL
d. Cardio-pulmonary clearance before
surgery and cardiac monitoring during Subject to MBL
surgery.
4 Standard Nursing Services Subject to MBL
5 Medicines for in-patient use Subject to MBL
Blood products transfusions and
6 intravenous fluids, including blood Subject to MBL
screening and cross matching.
X-Ray, laboratory examinations, routine,
7 diagnostic tests and therapeutic Subject to MBL
procedures incidental to confinement
Dressings, conventional casts (plaster of
8 Subject to MBL
Paris) and sutures
9 Anesthesia and its administration Subject to MBL
1
Oxygen and its administration Subject to MBL
0
11 Standard Admission kit Subject to MBL
All other items directly related in the
1 medical management of the patient, as
Subject to MBL
2 deemed medically necessary by the
attending Accredited Physician
D. DIAGNOSTIC PROCEDURES
1 12-Lead Electrocardiogram (ECG) 100% of Actual Cost subject to MBL
24-Hour Electroencephalogram (EEG)
2 100% of Actual Cost subject to MBL
Monitoring
3 24-hour Holter Monitoring 100% of Actual Cost subject to MBL
4 Adrenocortical Function 100% of Actual Cost subject to MBL
Anti-Nuclear Antibody, C-Reactive Protein,
5 100% of Actual Cost subject to MBL
Lupus Cell Exam
6 Arterial Blood Gas 100% of Actual Cost subject to MBL
Arthroscospic Procedures, Orthopedic
7 100% of Actual Cost subject to MBL
Arthroscopy
8 Audiograms and Tympanograms 100% of Actual Cost subject to MBL
9 Bone Densitometry Scan (Dexascan) 100% of Actual Cost subject to MBL
1
Bone Mineral Density Studies 100% of Actual Cost subject to MBL
0
Cardiac Stress Tests (Thalium and
11 100% of Actual Cost subject to MBL
Dipyridamole Stress Tests)
1
Computed Tomography Scans 100% of Actual Cost subject to MBL
2
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
16
1
Diagnostic Radiographs:
3
a. Biliary tract: Cholecystogram and
100% of Actual Cost subject to MBL
Cholangiogram
b. Chest, ribs, sternum and clavicle 100% of Actual Cost subject to MBL
c. Digestive: Plain film of the abdomen,
Barium Enema, Upper GI Series, Lower GI 100% of Actual Cost subject to MBL
Series, Small Bowel series
d. Face (including sinuses), Head and
100% of Actual Cost subject to MBL
Neck
e. Urinary: Kidney, Ureter, Bladder (KUB),
100% of Actual Cost subject to MBL
Pyelograms and Cystograms
f. X-ray of the extremities and pelvis 100% of Actual Cost subject to MBL
g. X-ray of the spine (cervical, thoracic,
100% of Actual Cost subject to MBL
lumbo-sacral)
1
Diagnostic Ultrasounds:
4
a. 2D-Echo with Doppler 100% of Actual Cost subject to MBL
b. Abdomen 100% of Actual Cost subject to MBL
c. Duplex Scan 100% of Actual Cost subject to MBL
d. Digestive and Urinary Systems 100% of Actual Cost subject to MBL
e. Ultrasound of the Lungs 100% of Actual Cost subject to MBL
1
Electroencephalogram (EEG) Monitoring 100% of Actual Cost subject to MBL
5
1 Electromyelography and Nerve
100% of Actual Cost subject to MBL
6 Conduction Studies
1
Endoscopic Procedures 100% of Actual Cost subject to MBL
7
1
Fluorescein Angiography 100% of Actual Cost subject to MBL
8
1
Impedance Plethysmography 100% of Actual Cost subject to MBL
9
2
Magnetic Resonance Angiography (MRA) 100% of Actual Cost subject to MBL
0
2
Magnetic Resonance Imaging (MRI) 100% of Actual Cost subject to MBL
1
2
Mammography and Sonomammogram 100% of Actual Cost subject to MBL
2
2
Myelogram 100% of Actual Cost subject to MBL
3
2
Nuclear Radioactive Isotope Scan 100% of Actual Cost subject to MBL
4
2
Pap's Smear 100% of Actual Cost subject to MBL
5
2
Perfusion Scan 100% of Actual Cost subject to MBL
6
2 Plasma Urinary Cortisol, Plasma
100% of Actual Cost subject to MBL
7 Aldosterone
2
Polysomnograms (Sleep Recording) 100% of Actual Cost subject to MBL
8
2
Pulmonary Function Tests 100% of Actual Cost subject to MBL
9
3 Radioisotope Scans and Function
0 Studies:
a. Cardiac 100% of Actual Cost subject to MBL
b. Gastrointestinal 100% of Actual Cost subject to MBL
c. Liver 100% of Actual Cost subject to MBL
d. Parathyroid Bone, Pulmonary
100% of Actual Cost subject to MBL
(Perfusion/ Ventilation Lung Scans)
e. Renal 100% of Actual Cost subject to MBL
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
17
f. Thyroid Scans 100% of Actual Cost subject to MBL
g. Total Body Scans 100% of Actual Cost subject to MBL
3
Radionuclide Ventriculography 100% of Actual Cost subject to MBL
1
3
Surface Electromyography (SEMG) 100% of Actual Cost subject to MBL
2
3
Thallium Scintigraphy 100% of Actual Cost subject to MBL
3
3
Treadmill Stress Test (TMST) 100% of Actual Cost subject to MBL
4
E. THERAPEUTIC PROCEDURES
Up to six (6) sessions subject to MBL for OP; Up to
1 Arthrocentesis
MBL for IP
2 Dialysis Up to MBL shared limit for OP and IP
3 Intravenous Chemotherapy Up to MBL shared limit for OP and IP
Up to six (6) sessions subject to MBL for OP; Up to
4 Phlebotomy
MBL for IP
Shared limit of up to twelve (12) sessions/member/year
Physical therapy / Occupational therapy
subject to MBL for OP; Up to MBL for IP.
excluding subspecialties such as cardiac
5
rehabilitation, pulmonary rehabilitation and
Note: Therapy of one (1) body area shall be considered
the like.
as one (1) session.
Up to six (6) sessions subject to MBL for OP; Up to
6 Thoracentesis
MBL for IP
7 Therapeutic Radiology:
a. Brachytherapy Up to MBL shared limit for OP and IP
b. Cobalt Up to MBL shared limit for OP and IP
c. Linear Accelerator Therapy Up to MBL shared limit for OP and IP
d. Radioactive Cesium Up to MBL shared limit for OP and IP
e. Radioactive Iodine Up to MBL shared limit for OP and IP
Continuous Positive Airway Pressure
8 Up to Php 60,000 shared limit for OP and IP
(CPAP)
9 Oral Chemotherapy Up to Php 60,000 shared limit for OP and IP
G. PREVENTIVE CARE
Passive and active vaccines for treatment
1 Covered up to Php 40,000 / member / year
of tetanus and animal bites
2 Periodic monitoring of health problems Covered
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
18
Health-education and counselling on diets
3 Covered
or exercise
Health habits and Family Planning
4 Covered
counseling
ADDITIONAL PROCEDURES AND MODALITIES (shared limit for OP and IP; Professional Fees, Hospital
H.
Bills and other incidental expenses relative to the procedure shall form part of the limit)
Angiography (gastrointestinal, brain,
1 100% of Actual Cost subject to MBL
retinal and peripheral vascular)
Coronary Angiogram and/or
2 100% of Actual Cost subject to MBL
Angioplasty/Coronary Artery Bypass Graft
3 Cryosurgery 100% of Actual Cost subject to MBL
4 Gamma Knife Surgery 100% of Actual Cost subject to MBL
5 Hysterescopic Myoma Resection 100% of Actual Cost subject to MBL
6 Hysteroscopically-guided D&C 100% of Actual Cost subject to MBL
7 Laparoscopy 100% of Actual Cost subject to MBL
8 Lithotripsy 100% of Actual Cost subject to MBL
9 Percutaneous Ultrasonic Nephrolithotomy 100% of Actual Cost subject to MBL
1
Stereotactic Brain Biopsy 100% of Actual Cost subject to MBL
0
11 Conventional Hemorrhoidectomy 100% of Actual Cost subject to MBL
1
Scalpel Hemorrhoidectomy 100% of Actual Cost subject to MBL
2
1
Stapled Hemorrhoidectomy Covered up to Php 5,000 /member /year
3
1
Mammotome Covered up to Php 5,000 /member /year
4
1 4D Ultrasound except for maternity-related
Covered up to Php 5,000 /member /year
5 cases
1
Esophageal Manometry Covered up to Php 5,000 /member /year
6
1
Intensified Modulated Radiotheraphy Covered up to Php 5,000 /member /year
7
1 Botox which is not cosmetic in nature nor
Covered up to Php 5,000 /member /year
8 for beautification purpose
1
Positron Emission Tomography Covered up to Php 5,000 /member /year
9
2
CT Pulmonary Angiography Covered up to Php 5,000 /member /year
0
2
Photodynamic Therapy Covered up to Php 5,000 /member /year
1
Other medically necessary modalities not
2 mentioned above and those for which
Covered up to Php 5,000/ procedure /member /year
2 there are no comparable, conventional or
traditional counterparts
2 Transurethral Microwave Therapy of
Covered up to Php 25,000 /member /year
3 Prostate
I. EMERGENCY CARE
1 In Accredited Hospitals
a. Doctors services Subject to MBL
b. Emergency Room Fees Subject to MBL
c. Medicines used for immediate relief
Subject to MBL
during treatment
d. Oxygen, Intravenous fluids and blood
Subject to MBL
products.
e. Dressings, conventional casts (plaster
Subject to MBL
of Paris) and sutures.
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
19
f. X-Rays, laboratory and diagnostic
Subject to MBL
examinations, and other medical services
related to the emergency treatment of the
patient.
g. Room Upgrade in case of room
up to 24 hours
unavailability
Reimbursable up to 80% of hospital bills & professional
fees based on Maxicare rates incurred during the first
2 In Non-Accredited Hospitals
24 hrs. of treatment up to Php 30,000 / availment /
member /year
Reimbursable up to 100% of actual cost up to
3 Outside the Philippines
Php30,000 / availment / member / year
4 Areas without Accredited Hospital 100% based on Maxicare rates up to MBL
Ambulance Service (Accredited
5 Hospital/Clinic to Accredited Up to MBL
Hospital/Clinic)
Ambulance Service (Non-accredited
6 Hospital/Clinic to Accredited Reimbusable up to Php 2,500 per conduction
Hospital/Clinic)
Note: The ambulance service provided herein shall be available regardless of the location within the
Philippines
Covered for the first 24 hrs. from the time of bite
7 Initial Treatment of Animal Bites
subject to MBL
J. PRE-EXISTING CONDITIONS
1 Dreaded Conditions Covered depending on the type of Product
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
20
Any loss or expense caused by or resulting from the following will not be paid:
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
21
O. MEMBERSHIP GUIDELINES
1 Age Eligibility
Principals 18 up to 65 years old
Adult Dependents 18 up to 65 years old
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
22
Minor Dependents 15 days old up to 21 years old
* Enrollees age 66 years old & above shall not be covered
* Dependents should be the same plan or lower than the Principals, on a per level basis.
* No coverage for extended dependents.
2 Hierarchy of Enrollment to be followed:
Legal spouse must be enrolled first, followed by the
Married Employees
eldest to the youngest child.
Both parents (anyone ahead of the other) and then the
Single Employees
siblings (eldest to the youngest)
Children (eldest to youngest) and/or Parents (anyone
Single Parent Employees
ahead of the other) and siblings (eldest to youngest)
There will be a thirty (30) days grace period to enroll their eligible dependents. Otherwise, only newly
* wed, newly born and dependents of newly regularized employees shall be considered for enrollment after
the 30 days grace period.
3 Participation Requirement
100% of all eligible employees should enroll all the
eligible dependents under the program or the number
a. Non-contributory accounts
of dependents should reach 75% of the total number of
principals.
P. ESCALATION CLAUSE:
1 at least 75% standard rates
2 60% - 74.9% + 10% to standard rates
3 40% - 59.9% + 20% to standard rates
4 Below 40% + 35% to standard rates
Above escalation clause shall apply and subject to change to the following cases:
a. If there is a significant decrease from initial count to actual number of enrollees. Participation
requirement is computed as total number of actual enrollees divided by total number of initial count prior
effectivity of the account.
b. If enrollment of dependents is open to all employees then participation requirement is below 75%. This
is regardless if account is contributory or non-contributory. Participation requirement is computed as total
number of eligible dependents divided by the number of principals that has eligible dependents only.
c. If the account limits the dependent's enrollment on a per rank classification, participation requirement is
computed as total number of eligible dependents divided by the total number of principals of the account.
Q. ENROLLMENT GUIDELINES
1 Application Forms Waived
2 Masterlist of Enrollees Maxicare Format
Medical Requirements* (at the applicant's
3 Waived
account)
Other medical requirements if deemed
4 Waived
necessary
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
23
NOTES:
The coverage for the Special Diagnostic Procedures are subject to the recommendation of the accredited
1 physician if medically necessary and the provisions of the dreaded and non dreaded pre-existing
conditions.
Above limits are inclusive of room & board, operating room charges, professional fees and other
incidental expenses relative to the procedure. The maximum benefit limit shall be inclusive of
2
consultations, routine procedures, diagnostic and therapeutic procedures and hospitalization. All
procedures or benefits are subject to the limitations on pre-existing conditions as stated in this proposal.
Can be assigned to selected employees only Semi Executive Check Up, Executive Check Up
Outpatient, Executive Check Up Overnight, Fee for
Service, Maternity
Can be assigned to either all employees and All the riders
dependents (combined) or for all employees only
N
RIDER INCLUSIONS & DESCRIPTIONS
O
to be availed at an Maxicare accredited ACU provider
lab inclusions are Physical, Chest Xray, Urinalysis, Urinalysis, Fecalysis, Complete Blood
Annual Count, ECG (for 35 & above) & Papmsmear (for female 35 & above)
Check up
1 can be availed after settling the 1st SOA for accounts under Annual & Semi Annual mode and 2
Routine
(Clinic) quarters for accounts under Quarterly mode
to be scheduled at least 2 weeks in advance by filling out the ACU Request Form
results are for pick up or delivery
Annual similar with ACU Routine Clinic except that this is done in the
Check Up premises of the account
2
Routine there must be a minimum of 50 confirmed members that will avail the Mobile ACU
(Mobile)
through Dental Hub. Availent is done through individual appointment by calling the dentist
directly
Annual Dental examination and consultation
Emergency out-patient dental treatment - to be availed at accredited dental clinics only
Oral Prophylaxis once a year
Simple tooth extractions
Restorative and prosthodontic treatment planning
Temporary fillings
Standard
Dental (1 Desensitization of hypersensitive teeth up to 2 teeth
3 oral Simple adjustment and repair of dentures.
propahylaxis Re-cementation of loose crowns, bridges, inlays and onlays.
) Dental nutrition and dietary counseling.
Dental health education.
Permanent fillings (not applicable for basic dental package)
Palliative treatment for simple mouth sores and blisters
Open incision and drainage (intraoral)
Pre-natal check of teeth and gums
Temporo Mandibular Joint Consultation (Initial consult only, referral to specialist not covered)
Gum Treatment for cases like inflammation or bleeding
4 Life Insurance Provider The Manufacturers Life
Insurance Insurance Co. (Phils.), Inc.
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
24
(Manulife)
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
25
Note: Loss of hands and feet shall mean dismemberment by severance at or above the wrist or
ankle joints respectively; loss of eyesight should be total and irrecoverable.
Conversion privilege
A member whose insurance coverage terminates due to separation from employment, has the
privilege of converting his/her individual Group Term coverage to an Individual Permanent plan
without having to submit any evidence of insurability subject to the following conditions:
The written application for the individual policy and the first premium payment for such were made
within thirty-one (31) days from date of separation.
The individual policy selected shall be any plan customarily issued by Manulife Philippines except
term and other supplemental plans.
The sum assured on the individual policy must not be more than the amount on the members life
insurance that was terminated and must not be less than the minimum required by Manulife for the
plan selected.
The premium rate on the individual policy applied for shall be based on the companys rate
applicable to both the class of risk to which the member belongs and his/her then attained age.
The policy will become effective at the end of 31 days after the date of termination of the
members employment.
Free Insurance Coverage
A member whose coverage terminates is covered for an additional thirty-one (31) days from date
of termination of membership, free of charge, whether or not he/she avails of the conversion
privilege.
Termination
This benefit will automatically terminate on the first of the following events:
Full-time employment means employment on a regular schedule of at least thirty hours per
week, at his employers regular place of business or other location where his employers business
specifically requires him to be in performance of such work.
Delete if dependents are not to be enrolled
Spouse/Parent 18-65 years old
Children/Sibling Not more than 21 years old
B. Eligible Dependents
Legal spouse and Children
i.) Dependents of Married employees who are in good health at
the inception of the policy.
Children and
Parent/Siblings who are in
iii.) Dependents of Single Parent Employees
good health at the
inception of the policy.
Note: Coverage and exclusions shall still subject to the terms and conditions of the Insurance
provider.
The Philippine American
Insurance Provider Life & General Insurance
Company (Philam Life)
Cancer Benefit Php200,000/member
Death Benefit
i.) If not diagnosed as terminally ill Php20,000/member
ii.) If diagnosed as terminally ill Php10,000/member
Terminal Illness Benefit Php10,000/member
Definition of Terms
Cancer - the occurrence of a histologically confirmed invasive malignant tumor involving the
spread of malignant cells. Spread of malignant cells means spread of malignant cells to lymph
nodes or distant parts of the body which is also known as metastatic stage. This criterion must be
satisfied if cancer is diagnosed within the 7th to 24th month of coverage; but this criteria is not
required if the cancer is first diagnosed after the Contract has been in force for two (2) years from
the Effective Date or the latest date of any Reinstatement, whichever is the latest. Any stage of
cancer is qualified for coverage on the 25th month and onwards.
Cancer Benefit the lump sum amount to be paid to the Member if the Member is diagnosed by
Cancer an accredited physician to have contracted a cancer illness after the waiting period.
5 Benefit
(Php200,000) Death Benefit - the amount to be paid to the beneficiaries of the Member if the Member dies while
still a member of Maxicare.
Terminal Illness Benefit portion of Death Benefit that will be advanced in lump sum to the
Member if the Member is medically diagnosed as terminally ill with a life expectancy of twelve (12)
months or less.
Waiting Period refers to the length of time after the members effective date within which Cancer
Benefit is not payable to the Member.
No Evidence Limit (NEL) is the limit within which no evidence of insurability will be required. If
coverage is beyond this limit, then a health statement will be required and from the declarations on
this health statement, shall assess if medical examinations will be required.
Waiting Period
Cancer illness diagnosed after members effective date shall be payable in accordance to the
following waiting period:
i.) Cancer is diagnosed to be in metastatic stage after one hundred eighty (180) days from
members effective date; or
ii.) Cancer is diagnosed in any stage after two (2) years from members effective date or latest
reinstatement date.
No Evidence Limit (NEL) is Php1,000,000
For any amount of insurance in excess of NEL, proof of good health must be submitted (i.e.
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
27
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
28
g. Kaposis Sarcoma;
h. Other tumors associated with Human Immuno-Deficiency Virus (HIV) infection; and
i. Tumors that pose no threat to life and for which no treatment is required.
ii.) Pre-existing conditions are excluded within the first twelve (12) months of a Members
coverage. Pre-existing conditions are conditions for which the Member received treatment,
diagnosis, consultation or prescribed drugs in the six (6) months preceding Members effective
date.
iii.) Any illness or surgery, other than a diagnosis of, or surgery for cancer.
iv.) Cancer was diagnosed prior to, or within one hundred eighty (180) days following the Effective
Date or the latest date of any reinstatement of the respective Member whichever is later.
v.) If the Member seeks medical advice or treatment for any signs or symptoms for such illness
which, based on the findings of Philam, first manifested or occurred prior to, or within one hundred
eighty (180) days following the Effective Date of Coverage or the latest date of reinstatement of
the respective Member whichever is later.
vi.) Cancer which was diagnosed due, directly or indirectly, to a congenital defect or disease
which has manifested or was diagnosed before the Member reached seventeen (17) years of age.
vii.) Cancer caused directly or indirectly, wholly or partly, by
a. self-inflicted injury; or
b. addiction to alcohol or drugs not prescribed by a medical doctor; or
c. while under the influence of alcohol or unprescribed drugs; or
d. atomic or nuclear radiation; or
e. Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus(HIV); or
f. pregnancy and resulting childbirth, miscarriage or abortion; or
g. cosmetic or plastic surgery, except as a result of injury; or
h. war or any acts thereof; or acts of terrorism; or
i. homicide, frustrated homicide or any attempt thereof, or physical injuries; or
j. automobile and motorcycle racing, judo, karate and similar martial arts, scuba diving,
hang-gliding and sky gliding.
Note: Coverage and exclusions shall still subject to the terms and conditions of the Insurance
provider.
Female Employees
(Married or Single/Married
Covered Members
only) and Spouse of Male
Employees
Maxicare shall cover the hospital bills and professional fees incurred by covered Member for
maternity services/procedures, up to the following limit:
Normal Delivery Php5,000
Caesarian Php10,000
Miscarriage and Abortion Php5,000
LOA-facilitated if availed
Maternity within the network; and
6
Benefit shall be on reimbursement
Type of Availment basis based on actual
amount and subject to
above mentioned limits if
availed outside the network
Philhealth benefits On top of Maternity Limit
280 days Waiting Period Not Applicable
Laboratory procedures/work-ups Not Covered
For availments in Accredited Hospitals but with Non-Accredited Physicians, Maxicare shall provide
outright coverage for the hospitals bills and the professional fees of Non-Accredited Physicians
shall be on a reimbursement.
Insurance Company of
International
7 North America (A Chubb
Assistance
Insurance Provider Company)
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
29
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
30
Notwithstanding any provisions to the contrary, the following shall not be covered except otherwise specified in
Maxicare Benefits
1 Services obtained for non-emergency conditions from Physicians and Hospitals in any of the following
circumstances
a. non-Accredited Physicians in non-Accredited Hospitals
b. non-Accredited Physicians in Accredited Hospitals
c. Accredited Physicians in non-Accredited Hospitals or other non accredited healthcare facility.
2 Additional hospital charges and physician's professional fees resulting from:
a. room-upgrading beyond Member's allowable time during emergency care
b. extension of hospital stay despite release of discharge order from Member's attending physician
c. fees of the assistant surgeons / resident doctors who assisteed the Attending Physician in the process of
rendering the above mentioned services shall not be chargeable to the Member and/or Maxicare except for hospitals that
do not have resident physicians to assist during surgeries subject to the prior approval of Maxicare
d. use or extra bed, TV, electric fan, DVD/VCD, and other similar items unless such appliances and items are
necessarily and ordinarily medical services brought about by obtaining a room accommodation higher than the Member's
Room and Board Accommodation limit
e. extra food
f. toilet articles like face towel, soap, toothbrush and the like
g. difference in room and board, the incremental rate differences for professional fees, diagnostic and laboratory
examinations, and other ancillary medical services brought about by obtaining a room accommodation higher than the
Member's Room and Board Accommodation limit;
h. services of a private or a special nurse;
i. all other items not medically necessary in the medical management of the patient.
3 Custodial, domiciliary, convalescent and intermediate care.
4 Long-term rehabilitation and psychiatric and/or psychological illnesses and conditions including neurotic and
psychotic behavior disorders; anxiety disorders/
5 Treatment for injury and its complications resulting from self-inflicted injuries including infections as a result of
tattoos, piercing of the ear or in any body part, whether self-inflicted or done by a third party or attempted suicide or self-
destruction, whether sane or insane.
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
31
6 Developmental disorders including functional disorders of the mind, such as but not limited to Attention-Deficit
Disorder (ADD)/Attention-Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders, Bipolar Disorders, Central
Auditory Processing Disorder (CAPD), Cerebral Palsy, Down Syndrome, Neural Tube Defects, and Mental Retardation.
7 Treatment of any injury received when there is negligence, unauthorized use of prohibited drugs or regulated
drugs, alcoholic liquor intake, direct or indirect participation in the commission of a crime whether consummated or not,
violation of a law or ordinance or unnecessary exposure to imminent danger, knowingly or unknowingly or hazard to
health, by the Member. Maxicare may rely on the Police or Doctor's report to evaluate such claim.
8 Aesthetic, cosmetic and reconstructive surgery or any consultation or treatment for any beautification purposes
except if necessary to treat a functional defect due to accidental injury within the initial confinement.
9 Oral surgery following accidental injury to teeth for purposes of beautification. Dental examinations, extractions,
fillings, other dental treatment and their complications except to the extent that are medically necessary for repair or
alleviation of damage to the Member caused solely by an accident. Medical care resulting from any dental related
conditions.
10 Maternity care and all other conditions (except pre and post natal consultations) related to and/or resulting from
pregnancy and/or delivery which affect the conditions of the Member and the unborn child.
11 Circumcision (except for treatment of urological conditions), sex transformation, diagnosis, treatment and
procedures related to fertility or infertility, artificial insemination, sterilization or reversal of such and their complications.
12 Experimental medical procedures and its complications.
13 Acupuncture, chirotherapy and other forms of therapies and its complications.
14 All expenses incurred in the process of organ donation and transplantation if the Member is the donor of such
donation or transplantation, and its complications.
15 Routine physical examinations required for obtaining or continuing employment, requirement in school,
insurance/travel or government licensing, health permit and other similar purposes.
16 Purchase or lease of durable medical equipment, oxygen dispensing equipment, and oxygen except during
covered in-patient care.
17 Corrective appliances, prosthetics and orthotics such as but not limited to eye glasses and contact lenses,
hearing aids, pacemaker, artificial limbs, valves, knee-tibial insert for total knee arthroplasty, vascular grafts, titanium
thread, myringotomy tube, intravascular catheters, vascular stents, bone screws/plates, pins, wires, balloons,
orthopedic internal fixator/fixation systems, orthopedic external fixator/fixation systems, intraocular lens, braces,
crutches.
18 Take-home medicine and out-patient medicine except:
a. chemotherapy medicine
b. medicine administered during an emergency treatment
19 Congenital, genetic and hereditary diseases and their complications (except for hernias) affecting functions of
individuals.
20 All physical deformities prior to enrollment.
21 Treatment of injuries/illnesses caused directly or indirectly by engaging in any professional sport or hazardous
activity such as but not limited to scuba diving, surfing, water skiing, mountain climbing, rock climbing, mountaineering,
parachuting, airsoft, drag racing, paintballing, wakeboarding and bungee jumping, except for activities under company-
sponsored sports activities.
22 Injuries resulting from direct participation in riots, strikes, and other civil disturbances.
23 Treatment of injuries or illnesses resulting from war or any combat-related activities while in military service.
24 Sexually transmitted diseases, genital warts, AIDS and AIDS related diseases.
25 Valvular heart disease (congenital and/or acquired) including Cardiomyopathies, Chronic Glomerulonephritis,
previous craniotomy sequelae/hearing impairment/ Neurologic disease and Spinal Stenosis (if pre-
existing)/Poliomyelitis/Slipped disc (if pre-existing) and Guillain-Barre Syndrome, Diabetes and its complications (if pre-
existing), Complicated Hypertension (e.g. those with history of stroke, myocardial ischemia or infarction and poor kidney
function), and all malignant tumors (if pre-existing).
26 Treatment for chronic dermatoses.
27 Infectious diseases (i.e. Avian Flu, Meningococcemia, etc.) that are declared epidemic or pandemic by the
Department of Health, World Health Organization or any recognized health authority.
28 Pre-existing Hepatitis B and screening and vaccines for all types of Hepatitis.
29 Animal bite/scratch/lick or snake bite including its complications.
30 Benefits covered by Philhealth and all other government funded healthcare entitlements as provided for by law.
31 Laser procedures/treatments.
32 Speech therapy for developmental and congenital diseases.
33 Weight reduction programs, surgical operation or procedure for treatment of obesity, including gastric stapling or
balloon procedures and liposuction.
34 Routine, diagnostic, therapeutic and other procedures of the same or similar nature not otherwise specified in
this Agreement.
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
32
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
33
q. Urinary Incontinence
List of Providers
LIST OF PROVIDERS
You may download the lists of providers at these links or request these from us.
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
34
CATEGORY INDUSTRIES
Construction (Office Based)
Education (except pre schools, tutorials & review centers)
Law Firms
Rated
Media
Pharmaceuticals (Distributors)
Sauna, Turkish bath, massage parlors (except spa, salons)
Construction (Field Based or combined)
Drillers (oil/water/gas)
Firemen
Full Time athletes
Government Institutions
Groups involving special hazards
Logging or Forestry
Manufacturers of Ammunitions
Medical Groups or any healthcare related
Ineligible Mining / Underground mine workers
NGO, Foundations, Cooperatives, Associations (if enrolling with members, if employees only yes)
Oil production
Pharmaceutical (manufacturing)
Political groups
Private households
Protection services (security guards)
Existing Maxicare Plus Accounts
Lapsed / Suspended/ Cancelled Maxicare Plus accounts w/ a high loss ratio (>120%)
Previous blacklisted accounts (fraudulent / bad payment habit)
INELIGIBLE INDUSTRIES
This proposal is not applicable to companies who fall under the list of Ineligible Industries. Requirements must be
submitted for quotation before a proposal can be submitted.
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
35
(found at the last 3 pages of this initial 6. Detailed Master list with Rank Classification, Job Designation and
proposal) Description, Birthdays / Age, Gender. You may download the template
here http://tinyurl.com/maxicaredetailed
HOW TO SUBMIT THE REQUIREMENTS:
Option 1: (Via Email) You may scan the document and email it back to us.
Option 2: (Via Fax) You may also fax it to us at (02) 819-9899
ALL COMPANIES & INDUSTRIES WITH 100 EMPLOYEES & UP (OR EMPLOYEES AND DEPENDENTS IF
COMBINED REACHES 100)
Mandatory Requirements to Generate a Pricing Proposal:
NGOs/Foundations/Cooperatives/Associations with
All companies with 100 employees & up
100 employees and up
1. Signed Maxicare Prospective Account Form. You may
download the form at http://tinyurl.com/maxicarepcaf
1. Signed Maxicare Prospective Account Form. You may
download the form at http://tinyurl.com/maxicarepcaf 2. SEC Registration Certificate and/or Cooperative
Developing Authority Certificate of Registration (for
Cooperatives)
3. Signed Questionnaire for Rated Accounts. You may
2. Excel Softcopy of Company Masterlist (with birthdates or download the form here
age, gender, ranks/classification) http://tinyurl.com/maxicarequestionnaire
4. 2 Year Audited Financial Statements
5. Detailed Master list with Rank Classification, Job
3. Filled out Maxicare Product Mix Survey Form. You may Designation and Description, Birthdays / Age, Gender
download the form here 6. Filled out Maxicare Product Mix Survey Form. You
http://tinyurl.com/maxicareproductmix may download the form here
http://tinyurl.com/maxicareproductmix
HOW TO SUBMIT THE REQUIREMENTS:
Option 1: (Via Email) You may scan the document and email it back to us.
Option 2: (Via Fax) You may also fax it to us at (02) 819-9899
Enrollment Guidelines
PLAN TYPES FOR EMPLOYEES
The following enrollment set up can be applied when choosing a plan type for all the employees. Note that the enrollment
set up cannot be modified in the middle of the coverage. Creation of additional plan types not chosen at the onset is not
allowed.
1.) Same Plan for all Employees can be selected for all employees (eg. Everyone under Gold 3 Plan)
Example:
Level Employees Plan Type Comments
Executives Gold 3
Managers Gold 3 Uniform plan for all employees
Staff Gold 3
2.) Different Plan Types. Higher Positions must have higher plans. Lower Positions must have lower plans. Employees
with the same position must have the same plan type.
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
36
Example:
Level Employees Plan Type Comments
Executives Platinum 1
Managers Gold 1 Choosing different plan types must be
Staff Silver 1 consistent with respect to the rank/level.
a) The dependents plan could be uniform with respect to the categories or ranks within the company.
Level Employees Plan Type Dependents Plan Type Comments
Executives Platinum 1 Platinum 1 Same plan with employee
Managers Gold 1 Gold 1 Same plan with employee
Staff Silver 1 Silver 1 Same plan with employee
b) The dependents plan can be 1 plan lower (only) but must be uniform across all levels
c) The dependents plan for all dependents can be the same plan with that of the lowest plan assigned to the employees
d) The dependents plan for all dependents can be the same plan 1 plan lower (only) with that of the lowest plan
assigned to the employees
KYC REQUIREMENTS
The following KYC requirements are required and will be submitted upon submission of the signed conforme
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
37
6. Photocopy of at least one (1) valid Government issued ID of owner/authorized signatory. Any
of the ff:
i. Driver's
ii. GSIS-E Card
iii. Passport
iv. Philhealth
v. PRC
vi. SSS
vii. TIN
viiii. UMID
ix. Voter's
7. Signed Maxicare Masterlist (to be provided by the agent upon submission of final masterlist)
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
38
SOLE
ADDITIONAL REQUIREMENTS FOR SPECIAL CASES:
PROPRIETORSHIP
A. If Signatory is not the President / CEO or the highest ranking officer, proof of authority to sign
in behalf of the entity
i. Notarized appointment letter
ii. Special Power of Attorney or similar document
B. For companies that are VAT-Exempt or Zero-Rated
i. Philippine Economic Zone Authority (PEZA) and/or Board of investments (BOI) certificate
ii. BIR Certificate of Registration (BIR 2303)
1. Chartered Document
2. Photocopy of at least one (1) valid Government issued ID of owner/authorized signatory
(Drivers, GSIS-E Card, Passport, Philhealth, PRC, SSS, TIN, UMID, Voter's)
3. Maxicare Questionnaire for Rated Accounts
GOVERNMENT
AGENCIES / LOCAL ADDITIONAL REQUIREMENTS FOR SPECIAL CASES:
GOVERNMENT A. If signatory is not the procurement head, head of the agency or head of the local
Government, proof of authority of the signatory
i. Resolution duly certified by the managing body, or
ii. Notarized appointment letter
iii. Special Power of Attorney or similar document
1. Letter credence for their representative stating
EMBASSY
2. Photocopy of at least one (1) valid Government issued ID of owner/authorized signatory
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
39
Enrollment Form
Company Name:
Nature of Business:
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
40
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
41
EMPLOYEES
Last Name First Name MI Extension Employee no. Position Date of Birth Sex Civil Status Plan
Legend:
1 First Name
2 Middle Name
3 Last Name
4 Extension Name Jr. / Sr. / I, II, III, IV etc.
5 Employee No
6 Position
7 Date of Birth mm/dd/yyyy format
8 Sex Either F for female or M for male
9 Civil Status Single / Married / Separated / Widowed / Divorced
10 Plan Platinum1, Gold2, Silver2 , Bronze
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
42
DEPENDENTS
Legend:
1 First Name
2 Middle Name
3 Last Name
4 Extension Name Jr. / Sr. / I, II, III, IV etc.
5 Relationship Either as spouse, child, siblings or parent
6 Principal Name of the employee
7 Date of Birth mm/dd/yyyy format
8 Sex Either F for female or M for male
9 Civil Status Single / Married / Separated / Widowed / Divorced
10 Plan Platinum1, Gold2, Silver2 , Bronze
For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com