KAISER INTERNATIONAL HEALTH CARE PROGRAM

HEALTHGROUP, INC. ®
MEMBERSHIP APPLICATION

I hereby apply for membership of the Proposed Member below in the Health Care of Kaiser International Healthgroup, Inc.
(Kaiser) described herein subject to the Contract Provisions set forth in this Application, I agree that this Application and my
declarations and answers below, written by me or under my directions, shall be the basis, and deemed part of the contract
between Kaiser and myself.

Proposed Member:
Last Name First Name Middle Name Height Weight
Montecillo Metina Balleta 51 102.51
Date of Birth Age Place of Birth Nationality Gender: Civil Status
05/16/1991 27 Brgy. Imelda Filipino Female Single
Catarman N. Samar
Complete Home Address Home Tel. No.: NA Email Address
Brgy. Imelda Catarman Northern Samar
Imelda Catarman Northern Samar metinamontecillo11@gmail.com
Mobile No.: 09128866487
Philippines 6400 Philippines
Occupation (describe duties briefly) Employer Employer’s Address
Teacher To Facilitate the students Deped-Northern Samar Catarman Northern Samar
monitor and evaluate learners progress.
TIN: Office Tel. No.: Port of Entry (if Seaman) Are you a Philhealth Member?
430783659000 NA Destination Country (if OFW) Yes 13025147284009060248816

Owner/Payor (If the Proposed Member is 10-17 old):

Last Name First Name Middle Name Height Weight

Date of Birth Age First Name Gender: Civil Status

Female Single

Complete Home Address Home Tel. No.: N/A Email Address

Mobile No.:
Occupation (describe duties briefly) Employer Employer’s Address

TIN: Office Tel. No.: Port of Entry (if Seaman) Are you a Philhealth Member?
Destination Country (if OFW) NA

Beneficiary/ies Age Relationship to Beneficiary/ies Age Relationship to

Owner Owner
1 Maria Balleta Montecillo 54 ParentMother 3 Vicente Balleta 39 Brother
Montecillo
2 Raquel Balleta Montecillo 37 Sister 4

Plan Data:

PLAN NAME: Ultimate Kaiser Health Builder

PLAN TYPE: 185,288
Mode of Payment: Monthly

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First Payment Php: PR / SATR NO. Contract Price Php: Installment Php: Payment Form:
3,147.00 185,288 2,647.00 cash

June 2013 Edition Application No: 2018122621t6u6c

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Answer all the questions pertaining to the Proposed Member or Owner/Payor (if the Proposed Member is 10-17 years old) by checking the appropriate box:

1. Have you ever:

a. Availed of any medical/surgical consultation or treatment? no
b. Known of any impairment in your health? no
c. Been hospitalized and/or undergone surgery? no
d. Tested positive for antibodies to AIDS/hepatitis? no
e. Had, or sought consultation for, or been tested or treated for, or told to have AIDS or HIV infection, IADS or HIVW
related condition, or any immunological disorder? no
f. Been advised to have nay diagnostic test, hospitalization or surgery which was not completed? no
g. In the past 3 months, ever had continuous and unexplained symptoms of fatigue, weight loss, diarrhea, enlarged lymph nodes, or
unusual skin lesions?
2. Have ever the habit of smoking cigarettes?
a. Stopped smoking in the last 5 years? no
b. Ever taken any habit-forming substance or drugs, alcoholic drinks in excess or had the abuse or treatment for smoking
habit or other addiction? no
3. Do you engage in any hazardous sport or vacation?
a. Been active in politics, as a candidate or in any other capacity during the last five years? no
4. Are you presently covered by any hospitalization or medical plan?
a. Have you applied for or received a pension, payment or benefit due to injury, sickness or disability? no
5. Have you ever been rejected for insurance/health care plans or offered insurance at higher premiums?
a. Ever had any application for insurance or reinstatement of reinsurance, declined, postpones or modified in a mount,
plan or rate with us or any other company? no
b. Any pending application for life, accident or health insurance with us or any other company? no
6. Are you taking regular medication or undergoing medical treatment or observation?
a. In the past 5 years, had any consultation, medical advice, diagnostic test, treatment, accident, illness, operation not mentioned
above? no

(For WOMEN only)

7. Are you pregnant? No
If yes, how many months?
Date of last delivery:
a. Ever had any disease of the breast or female organs or complications of childbirths? no
b. Ever had a papsmear that was abnormal or that had to be repeated? no
c. Ever had any family member who suffered from cancer of the breast? If yes, please give relationship/s and age of onset? no

8. Do you have a history of any of the following: (if yes, check the box)
[No] Asthma
[No] Tumors or internal organs
[No] Hemorrhoids & Anal Fistulae
[No] Tuberculosis
[No] Stine in urinary tract
[No] Hypertension
[No] Ear, nose, throat tumors
[No] Cataracts, Glaucoma
[No] Malignancies & blood dyscrasias
[No] Convulsion (epilepsy)
[No] Prostate problems
[No] Varicose veins
[No] Hernia (acuired)
[No] Diabetes mellitus
[No] Liver disease
[No] Collagen disease
[No] Injuries from accident/assault
[No] Single/multiple organ failure
[No] Craniotomy
[No] Cancer
[No] Endometriosis
[No] Diseases tonsils
[No] Gall bladder stone
[No] Kidney/urological disease
[No] Cardiovascular diseases
[No] Hyperthyroidism/goiter
[No] Sinus requiring surgery
[No] Gastric or duodenal ulcer
[No] Buerger’s disease
[No] Arthritis & bone disease
[No] Benign new growths
[No] Cerebrovascular accident
[No] Central nervous system lesions
[No] Spinal stenosis
If you answered “YES” to any of the questionnaire, please give details:

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Name & address of personal Physician: NA
Date of last consultation : 1999-11-30
Reason of last consultation : NA
(AUTHORIZATION TO FURNISH MEDICAL INFORMATION) Date
I hereby authorize and request you, or any person, organization or entity that has any record or knowledge of the health and/or that of,
to give to Kaiser International Healthgroup, Inc. any and all information that the Company may
desire and which is relative to any consultation, treatment or any other medical advice or examination I/we had. A Photostat (or similar copy)
of authorization shall be as valid as the original. This information is in connection with my application for life insurance only.

METINA BALLETA MONTICELLO

Signature Over Printed Name of Legal Guardian/Owner or Payor
Signature Over Printed Name of Proposed Member

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 • I hereby apply for insurance, as specified in the Health Care Program, and I agree that the said insurance coverage is based on the
truth of operations and health declarations stated herein and is subject to the provisions of the Group Master Insurance Policy issued
by the Insurance Company/ies. I hereby represent and declare to the best of my knowledge that I have not been confined on any
hospital. Sanitarium of infirmary nor received medical or surgical treatment in the last twelve (12) months; that I have never been
treated for heart condition, high blood pressure, cancer, diabetes, lung, kidney or stomach disorder or any other physical or mental
impairment in the last five (5) years and that I am in good health and physical/mental condition. )

Signature of Applicant or Payor

• I hereby apply for Health Care Program with “NO INSURANCE BENEFITS” (NIB)

Signature of Applicant or Payor

I declare that the statements and answers contained herein are full, complete and true, and if found otherwise, I agree that the Health
Care Agreement may be validated. I hereby authorize any person or entity having a record or knowledge of my health to give Kaiser all
information relative to hospitalization medical treatment or consultation that I may have undergone.

I agree that no binding agreement is created by mere signing of this application until it is accepted and approved by Kaiser
International Healthgroup, Inc. containing the contract provisions signed by the authorized officials of Kaiser International Healthgroup, Inc. is
issued to me.

IN WITNESS THEREOF, I have signed this Application this day of , 20 in

(city/province where Applicant purchased the Kaiser Plan).

METINA BALLETA MONTICELLO

Printed Name of Proposed Member
or Owner/Payor (if the Proposed Member is 10-17 years old)

Witnesses by:

BOBBY CAPANGPANGAN Noriel De Mesa

Agency Unit Associate’s Code

121057UAE

Agency Unit Associate’s Code

119961UAE

For Kaiser Office use only:

Processor’s Name/Signature Date

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