Census Provident Fund, Inc. Census Provident Fund, Inc.

PSA, 5/F, TAM Bldg., East Ave., Diliman, PSA, 5/F, TAM Bldg., East Ave., Diliman,
Quezon City Quezon City
Tel No. 2-6662401 Tel No. 2-6662401
Email: Provident.Fund@psa.gov.ph Email: Provident.Fund@psa.gov.ph

Date: _____________ Date: _____________

I, _____________________________________, assigned at I, _____________________________________, assigned at

___________________ (Division-Service / Regional / ___________________ (Division-Service / Regional / Provincial
Provincial Office) will avail the MediCard plan on (please mark Office) will avail the MediCard plan on (please mark check):
check): ROOM & MAXIMUM ANNUAL
ROOM & MAXIMUM ANNUAL BOARD BENEFIT PREMIUM
BOARD BENEFIT PREMIUM LIMIT (PhP) (PhP)
LIMIT (PhP) (PhP)
Ward (Open) 60,000.00 11,805.00
Ward (Open) 60,000.00 11,805.00
Semi-Private 80,000.00 13,629.00
Semi-Private 80,000.00 13,629.00 (Open)
(Open) Small Private 100,000.00 16.935.00
Small Private 100,000.00 16.935.00 (Open)
(Open) Large Private 150,000.00 20,214.00
Large Private 150,000.00 20,214.00 (Open)
(Open)
I fully understand the agreements as follows:
I fully understand the agreements as follows:
1. One-time full payment;
1. One-time full payment;
2. The CPFI Health Care Assistance benefit amounting to
2. The CPFI Health Care Assistance benefit amounting to PhP1,500 is waived for the year 2018, but this will be
PhP1,500 is waived for the year 2018, but this will be deducted to my premiums;
deducted to my premiums;
3. The balance will be under Special Loan under one-year
3. The balance will be under Special Loan under one-year repayment period with authorized salary deductions on
repayment period with authorized salary deductions on monthly basis at 5% interest rate per annum.
monthly basis at 5% interest rate per annum.

_________________________
_________________________ Signature over printed name
Signature over printed name