MEDIACORE ADVERTISING SERVICES

CONFORME LETTER
MAXICARE PLUS

July 18, 2018

MR. ANACLETO CANLAPAN IV

President
MEDIACORE ADVERTISING SERVICES
B3 L3 Kalapati Cor Lawin St Bankers Village 6
Sta Cruz Antipolo City

Thru: MR. LEOPOLDO MAGNAYE

Affiliated Independent Agent

Dear Mr. Canlapan IV:

Maxicare Healthcare Corporation (“Maxicare”) intends to commence addressing the healthcare needs of
MEDIACORE ADVERTISING SERVICES (“Client”) and to share with you an experience of full customer
satisfaction. In this regard, we would like to initiate the processing of your employees’ and dependents’
enrollment to their specially designed healthcare plan, preparatory to the processing of their membership
cards.

Attached with this Conforme Letter are the Annexes with scope of the medical services under our Maxicare
Plus healthcare program covering the one (1) year period and shall commence five (5) calendar days from
the date of Official Receipt issued by Maxicare. Please find the following documents for your acceptance and
conformity:

Annex A: Salient Features

Annex B: Service Agreement

Please also be informed of our Guidelines for your guidance and reference:

A. REQUIREMENTS FOR ENROLLMENT

1. Acceptance of enrollment of the Client shall be subject to evaluation and approval of Maxicare
based on the following:
1.1 Client’s nature of business should not fall under ineligible groups.
1.2 Participation requirement under Article VII (10) of Annex B should be satisfied.
1.3 Benefit program under Section C of Annex A should be on a uniform basis or superior
according to the rank classification.
1.4 Dependents can only have the same or lower benefits than their Principal. Also, uniform plan
must be implemented for all Dependents of an employee.
1.5 Riders under Annex A should be on a uniform basis. It may only differ per membership type.
1.6 There should be no modification of benefits within the coverage period.
1.7 If the Client is a previous client of Maxicare, approval will be based on Maxicare’s review of
previous utilization.
2. Documentary requirements:
For the purpose of commencing the enrollment of the Client’s employees and dependents, Client
shall submit the following:
2.1 Signed Conforme Letter with attached Annex A and B
2.2 Know Your Customer (KYC) Requirements
a. For the Client and its Affiliates
Sole ➢ Certificate of Registration issued by the Department of Trade and Industry
Proprietorships ➢ Proof of authority of the signatory to sign in behalf of the entity
➢ Photocopy of at least one (1) valid Government issued ID of owner/authorized
signatory
➢ For companies that are VAT-Exempt or Zero-Rated (to be submitted on a yearly

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 MEDIACORE ADVERTISING SERVICES

basis): (1) VAT-Exemption Certificate and/or Board of Investments (BOI)

Certificate, and (2) BIR Certification of Registration (Form 2303)

b. For the Employees

Filipinos ➢ BIR Form 2316 duly signed by the authorized signatories of Employer
➢ BIR 1604 / Alphabetical list (latest with stamped received by BIR)
➢ PhilHealth Members Data Form
➢ SSS Contribution List
Foreign ➢ Alien Employment Permit issues by Department of Labor and Employment
Nationals (required), or
(Expat) ➢ Photocopy of Alien Certificate of Registration Identity I-Card issued by Bureau
of Immigration.

3. Enrollment forms/excel file containing all information of the employee/members with the following
disclaimer “I hereby certify that the above information given are true and correct. Should any of
the information/statement be found to be untrue, misleading or if a material fact be omitted,
Maxicare reserves the right to immediately terminate the Agreement, without refund of fees paid,
if any, and without prejudice to criminal liability of agent/broker and officers/directors of the above
company for such untrue or misleading information.”

4. For Contributory accounts, Certification from the Client’s HR that the account is contributory.

Note: The above documents must be submitted prior to activation.

B. RENEWAL MEMBERSHIP GUIDELINES

1. Submission of the Client’s masterlist for renewal shall no longer be allowed. The Client’s existing
masterlist in Maxicare database shall be rolled over and shall comprise the Client’s Renewal
Billing.

2. Maxicare shall not render the services or activate the coverage unless this signed Conforme
Letter has been submitted to Maxicare prior to the Effective Date. However subject to Maxicare’s
sole discretion, it may render the services or activate the coverage even without the signed
Conforme Letter as long as there is proof that the Client accepted all the terms and conditions of
this Conforme Letter as well as its annexes.

3. Membership Movement
3.1 The Enrollment period during renewal will run for a period of thirty (30) calendar days from
Effective Date.

3.2 Member Movement (Addition/ Cancellation, Change of Plan, Correction of Details) shall be
handled as normal subsequent endorsements
a. Additional enrollees endorsed within the enrollment period shall be activated retro-
effective based on Client’s Effective Date. Addition and Cancellation of Membership,
Upgrading / Downgrading of Plan, correction of details shall be subject to the provisions
in Article VIII (3) of the attached Annex B.
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b. Endorsement processed on or before the 8 calendar day from the Effective date
(“Renewal Billing Cut-off”), shall be part of the Renewal Billing. Endorsement processed
beyond the Renewal Billing Cut-off shall be part of the subsequent billing.

3.3. Additional Enrollees

a. Additional enrollees endorsed within the enrollment period shall be activated retro-actively
based on Client’s Effective Date.
b. Enrollees endorsed for activation shall be processed within one (1) working day from the
date of receipt of endorsement.

3.4. Cancellation of Members

a. Cancellation of membership shall be processed within one (1) working day from receipt of
endorsement.

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 MEDIACORE ADVERTISING SERVICES

b. Effective date of cancellation shall be based on the date endorsed or receipt, whichever is
later. Any cancellation that would take effect prior to the date endorsed or receipt (“Retro
Cancellation”) shall not be allowed.
c. Standard refund provision shall be applied. See Article X (12) of the attached Annex B.

3.5. Change of Plan

a. Change of plan resulting from revision of account plan and benefits effective renewal
shall be processed within two (2) calendar days from the Client’s Effective Date.
b. Subsequent endorsements for Plan Upgrade / Downgrade shall follow standard
processing of three (3) working days from the date of receipt.
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4. Statement of Account (SOA) shall automatically generate on the 8 calendar days from the
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Effective date. SOA of Client with late renewal advice shall be processed on the 8 calendar days
from the date the Client’s Account’s Plan Details was processed.

5. For any dispute regarding the Renewal Billing issued, provisions in Annex
B, Service Agreement, regarding dispute on payment of membership fees shall be strictly
enforced.

5.1 Revisions for identified issues will be processed via Credit or Debit memo, whichever is
applicable.

C. MISCELLANEOUS

1. Maxicare shall provide the Conforme Letter and its Annexes (Salient Features and Standard
Service Agreement) to the Client. The Client assumes responsibility to ensure that they receive
copies of the standard Service Agreement and all Addenda thereto from Maxicare.
2. The Conforme Letter forms an integral part of the standard Service Agreement of Maxicare. The
provisions in Annex A Salient Features and Annex B Service Agreement are deemed
incorporated in this Conforme Letter insofar as they are applicable and not inconsistent with the
provisions hereof. Should there be any inconsistency between the provisions of this Conforme
Letter, and its Annexes, the Parties shall exert their best efforts to harmonize such inconsistent
provisions having in mind the intention of the Parties in executing this Conforme Letter and its
Annexes and giving effect thereto. In the event that the conflicting provisions cannot be
harmonized, the terms of Annex B standard Service Agreement shall prevail.
3. The signed Conforme Letter must be submitted to Maxicare prior the Effective Date. For Client
who confirmed renewal but without the signed Conforme Letter yet, Salient Features shall be
renewed at status quo.
4. In the event that the Client fails to sign the Endorsement / Addendum within ninety (90) days from
the Effective Date of coverage, Maxicare, at its option, reserves the right to suspend all services
under this Agreement.
5. All information given to Maxicare for use in connection with the transactions contemplated in this
Agreement (such as but not limited to members and/or their dependents’ personal details and
medical records) are true and based on authentic documents. Should any of the
information/statement be found to be untrue, misleading or if a material fact be omitted, Maxicare
reserves the right to immediately terminate the Agreement, without refund of fees paid, if any, and
without prejudice to criminal liability of agent/broker and officers/directors of Client for such untrue
or misleading information.

Please feel free to communicate with us for any clarifications.

Should you be amenable to the proposed program, please affix your signature below to signify your
conformity to our offer.

We at Maxicare Healthcare Corporation look forward to a mutually beneficial business relationship with you.

Thank you.

Respectfully yours,

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 MEDIACORE ADVERTISING SERVICES

____________________________
MARK ROGER BARCENAS
ACCOUNT OFFICER
Sales

We agree to abide by the above mentioned terms and conditions and cause our respective authorize
representatives to affix their respective signatures on this _________________ day of ________________,
________________ in Makati City.

MAXICARE HEALTHCARE CORPORATION MEDIACORE ADVERTISING SERVICES

By: By:

________________________________________ ________________________________________
CHARILOU T. BAUL MR. ANACLETO CANLAPAN IV
Business Development Manager President

________________________________________
CZELINE CHAN-DAYAG
Assistant Vice President - Sales

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Form Template Control: Product Development/December 5, 2017/FO-PD-0.016/Rev.07