A000A97088-20190811131238

DEPENDENT ENROLLMENT CONFIRMATION FORM [CY: 2019-2020]

EMPLOYEE INFORMATION

Employee Name: TARUC, EDJIE BOY

Position/Level: BUSINESS PROCESS ASSOCIATE
SBU/Department: NOT PROVIDED
Contact Number: - / 9155683386
Date of Birth: October 27, 1995
Employee ID: 264074
Hire date: 2017-04-24 00:00:00
Current Civil Status: Single

DEPENDENT INFORMATION
Dependent 1 Fullname: EDDIE SIMBULAN TARUC
Relationship to Employee: Father
Age: 43.84
Birthday: October 09, 1975
Gender: M Civil Status: Marri
ed
Dependent 2 Fullname: MYRA CAYABYAB TARUC
Relationship to Employee: Mother
Age: 42.16
Birthday: June 12, 1977
Gender: F Civil Status: Marri
ed
DEPENDENT ROOM AND BOARD BENEFIT LIMIT REMARKS/CATEGORY
Dependent 1 Semi-Private PHP 80,000.00 Company Paid
Dependent 2 Semi-Private PHP 80,000.00 Company Paid

Dependents can no longer be cancelled within the policy year once the enrollment is confirmed, except for the following conditions: Employee
resignation, Death of the dependent, Coverage of dependent with another HMO provider (subject to approval); Dependent will work overseas or live
abroad. Valid supporting documents must be submitted together with the deletion request.
ActiveLink is only collecting information based on standard Underwriting guidelines. Membership acceptance is still determined by your company's HMO
provider.

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2FA Request ID
 ACTIVELINK DATA PRIVACY CONSENT FORM

Strictly Confidential

August 11, 2019

In compliance with the Data Privacy Act of 2012, it is our duty to disclose how we intend to use and process the information we will collect
from you. Furthermore, we seek your consent with regards to the collection and processing of your personal and sensitive information that
will be captured during your registration and enrollment on this website and other ActiveLink services under your HMO program.

It is ActiveLink's top priority to safeguard the user's privacy and maintain the utmost confidentiality in connection with the data or
information that users share or upload through BMB or Benefits Made Better (Website and/or ActiveLink Mobile App), as well as other
ActiveLink services and activities. These include, but are not limited to, HMO Membership, STM Wellness Programs and Projects, Surveys,
APE, Utilization Reports and Analysis, Group Life Insurance, Retirement Program, Pre-Employment Examination, Clinic Management, etc.

By agreeing to this form and proceeding to use this facility, the services on this platform (www.benefitsmadebetter.com,
manulife@benefitsmadebetter.com (dedicated help desk email assigned for your account), inquiries@benefitsmadefbetter.com), and other
ActiveLink services and programs such as installation and use of ActiveLink Mobile Application, you agree (signify consent) to share your
personal and sensitive information and that of your dependents to ActiveLink. The data we collect, as applicable, includes but is not limited
to the following categories of information captured:

HMO Membership
First, Middle and Last Name
Civil Status
Birthdate
Supporting Documents (i.e. Birth Certificate, Marriage Certificate, etc.)
Gender
Employee Number
Email Address
Designation
Contact Details (Mobile/Phone Numbers, Home Address)
APE and Pre-Employment Examination
First, Middle and Last Name
Birthdate
Civil Status
Employee ID
Height, Weight and BMI
Gender
Results and Findings (X-Ray, CBC, Urinalysis, Fecalysis, Physical Exam, Visual Acuity, Pap Smear, ECG, Drug Test
Results, etc.)
Age
Civil Status
GYRT
First, Middle and Last Name
Civil Status
Employee ID
List of Beneficiaries
Gender
Birth Date
Monthly Salary
Sum Insured
BMB Website and Dependents Module (For Employees and Dependents as applicable)
First, Middle and Last Name
Civil Status
Birthdate
Supporting Documents (i.e. Birth Certificate, Marriage Certificate, Affidavits, etc.)
Gender
Principal and Dependents Relationship
Home Address
Mobile Number and Phone Number
Email Address
Signature
Utilization Reports and Analysis
First, Middle and Last Name
Civil Status
Birthdate
ICD Code
Gender
Monitored Cases
 Age
Working and Final Diagnosis Procedure (i.e. X-Ray, Blood Test, Diagnostic Examination, etc.)
STM Wellness Programs and Projects
First, Middle and Last Name
Vital Signs (Blood Pressure, Body Temperature, Respiration rate)
Gender
Employee ID Number
Birthdate
Medical History
Weight and Height
Medical condition
BMI Results (i.e. Body Fat Percentage, Body Fat Mass, Visceral Fat, Muscle Mass, Total Body Water, Bone Mass,
Physique Rating, Basal Metabolic Rate (BMR), Metabolic Age, Body Mass Index, Muscle Quality, Daily Calorie Intake,
Muscle Quality Score, Segmental Muscle Mass, Segmental Body Fat Percentages and Body Type)
Working Diagnosis
Consultation Result
Health is Wealth Monthly Assessment Report
Laboratory Results
Survey
IP Address
Name
Gender
Employee Id
Email Address

By proceeding to register and use this facility, I affirm that:

1. I hereby give consent to ActiveLink to collect, use, store, and process my personal and sensitive information collected for valid and
specified reasons by the BMB website, the ActiveLink Mobile App and other present and succeeding ActiveLink activities or
programs such as, but not limited to, HMO Membership, APE-PEME, GYRT, BMB Registration and Dependents Enrollment,
Utilization Report and Analysis, STM Wellness Program and Projects, Survey, etc.
2. I hereby allow ActiveLink to access HMO utilization data about me and all my enrolled dependents from my HMO provider to
generate utilization reports, validate claims/usage, and design or suggest utilization preventive programs.
3. I, as a principal, have been duly assigned by my dependent to act as their authorized representative, process documents, and attend to
other legal matters of representation necessary for the enrollment of their HMO policy and availment.
4. I am aware that ActiveLink may use third-party platforms to collect responses and other data or information through Wellness
Activities, or programs, or surveys. I believe that these platforms are thoroughly reviewed and aligned with ActiveLink's security
and confidentiality standards. I understand the nature of each third -party platform's functions, to wit:
i. Typeform is used to capture or generate information or data during STM Wellness Activities. (To know more about
TypeForm securing data or information, please visit: https://admin.typeform.com/to/dwk6gt).
ii. Survey Monkey is used to generate members' surveys for the improvement of service delivery to clients. (To know more
about Survey monkey's policy on protecting data or information, please visit:
https://www.surveymonkey.com/mp/legal/privacy-policy/)
iii. Mail-Chimp is used to deliver announcements via electronic mail to clients or members. (To know more about Survey
monkey's policy on protecting data or information, please visit: https://mailchimp.com/legal/privacy/)
5. I hereby give consent to ActiveLink to share my details with my Company HR, Company Clinic and other authorized personnel
involved in my HMO program, to aid in the creation of initiatives for improving my health and wellness, such as activities and
programs, improved utilization management, company clinic database to improve clinic services, reviews of HMO pricing and
availment claims, etc.
6. I hereby allow ActiveLink to safeguard my data beyond the end of its engagement with my company as provided by any prior
agreements, or to otherwise retain my data for a period not exceeding 5 years. Permission to use my personal information, and that
of my dependents, will not expire during the aforementioned period.
7. I hereby agree that ActiveLink's collection of data is not limited to my initial disclosure but extends to all subsequent entries or
updating of informationas well as prior information shared.
8. As per the Data Privacy Act of 2012 and its Implementing Rules and Regulations, I hereby agree that I am aware of my rights as a
data subject, which encompass the right to be informed, to object, to access, to correct, to ensure erasure or blocking, and to file a
complaint as necessary.
9. I agree that my data shall be stored and kept within the ActiveLink cloud server facility for the aforementioned period from the onset
of data collection or until prior valid request by the company. (To know more about how ActiveLink protects your data or
information, please see ActiveLink's Privacy Policy: https://www.benefitsmadebetter.com/page.php?page=privacy-policy)
10. I understand that my participation is voluntary and that I am free to withdraw any time and without my medical care or legal rights
being affected. You can exercise this right upon discovery and substantial proof of the following:

i. Your personal data is incomplete, outdated, false, or unlawfully obtained.

ii. ii. It is being used for purposes you did not authorize.
iii. The data is no longer necessary for the purposes for which they were collected.
iv. You decided to withdraw consent, or you object to its processing and there is no overriding legal ground for its processing.
v. The data concerns information prejudicial to the data subject — unless justified by freedom of speech, of expression, or of
the press; or otherwise authorized (by court of law)
vi. The processing is unlawful.
 vii. The personal information controller, or the personal information processor, violated your rights as data subject.
Should the data subject opt out of the list, any identifiable data shall be removed from file:

i. All identifiable data shall be removed from the file. However, any results or data without personal identifiable item shall be
preserved for research, study and reporting purposes.
ii. That all data linked to the data subject may not be recovered anymore given the delisting and deletion of any personal
identifiable data.

11. By signing below, or by digitally proceeding in providing consent via 2FA facility or similar tool within the website or mobile
application, I signify that I have read and understood all of the above provisions.

You, as a participant, have the right to access, modify, and cancel the processing of your personal data at all times upon informing
ActiveLink. To do so, please contact our data privacy support team at dataprivacy@activelinkbenefits.com.

Very truly yours,

3deb699c4977425a96269381b5700285 : 1366lZ1RdUP7AbeTNLGkf7d2
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2FA Confirmation Request ID
{space}

For Dependent of Legal Age: By affixing your signature below, you freely, knowingly and voluntarily given your
consent as described in this document.
Name Signature

EDDIE SIMBULAN TARUC

MYRA CAYABYAB TARUC

 MAXICARE DATA PRIVACY CONSENT FORM

Strictly Confidential

August 11, 2019

MAXICARE HEALTHCARE CORPORATION

Maxicare Tower
203 Salcedo Street, Legaspi Village
Makati City

ATTENTION: JEA ABEY GETALGA

Account Officer

EMMANUEL A. AGUILA
Business Development Manager

THRU: ACTIVELINK EMPLOYEE BENEFTIS CONSULTING, INC.

SUBJECT: MEMBER CONFORME

Gentlemen:

In reference to my and/or my dependent/s' healthcare plan procured by the Company, I hereby certify that I and my
dependent/s have read and understood the Summary of Coverage and Benefits of the Service Agreement executed by Maxicare
Healthcare Corporation ("Maxicare") and the Company including all procedures, benefits, exclusions, limitations and
conditions contained therein, and agree to be bound thereby. Furthermore, by availing the services of Maxicare, I and my
dependent/s acknowledge and agree to abide by all the membership terms and conditions published via Maxicare website at
https://maxicare.ph/member-terms.

In executing this document and in affixing my signature hereto, I confirm that:

1. I agree and understand that in the course of providing service/s to me or my dependents, Maxicare shall engage the
services of, and/or interact with, other third parties, such as, but not limited to its parent company, affiliated companies,
subsidiaries, financial advisors, affiliated third parties or independent/non-affiliated third parties and service providers,
whether local or foreign (collectively referred to as "Representatives").

2. I and my dependent/s have freely, knowingly and voluntarily given my consent for Maxicare and its Representatives to:

a. Obtain, collect, examine, process, and store copies of my and/or my dependents' personal information,
including sensitive personal information, privileged information, medical records or any other information
relative to my (and/or my dependents') hospitalization, consultation, treatment or any medical advice in
connection with the benefit/claim availed under the Agreement as may be deemed necessary by Maxicare.
Except as otherwise stated hereon, any information obtained relative to the authority herein given shall be
strictly confidential. The extent of the collection and processing shall be necessary and incidental to the
performance of the services contemplated in the Agreement.

b. Disclose such information to the Company, its representatives, agents and brokers, Maxicare and its
Representatives, including the service providers which will perform the services contemplated in the
Agreement, for any legitimate business purpose as Maxicare may deem appropriate, including but not limited to
outsourced processing of Maxicare transactions, profiling or historical statistical analysis, providing advice or
information which Maxicare and its Representatives believe may be of interest to me or the Company, to
effectively administer or manage my account, enhance customer services, or to communicate with me or the
Company for any purpose.

Processing is hereby understood to include any operation or any set of operations performed upon personal information
including, but not limited to, the collection, recording, organization, storage, updating or modification, retrieval,
consultation, use, consolidation, blocking, erasure or destruction of data. Processing would include both manual and
automated handling of personal information and storage and data transfers using various means including but not
limited to physical methods as well as electronic via information and communications systems employed by Maxicare
and its Representatives.
 3. I have been duly authorized by my dependent/s to sign and execute any and all documents and make representations for
and in his/their behalf as if the same were personally done by him/them.

4. I hereby warrant that we understand our rights and obligations pursuant to the Data Privacy Act and its implementing
rules and regulations. I and my dependents understand that we retain the right to: be informed, to object, to access, to
complain, to rectify, to request for filtering of certain information and to corresponding damages in case of violation of
our rights within the corresponding limitations as set forth in the pertinent laws.

5. I and my dependents hereby represent that, in order to provide the services contemplated in the Agreement, the
authorities herein provided shall be valid and existing during the term of the Agreement, including any extensions
thereof, and until necessary for the establishment, exercise or defense of any claims arising from the said Agreement.

6. I and my dependents hereby agree to hold Maxicare and its Representatives free and harmless from and against any and
all suits or claims, actions, or proceedings, damages, costs and expenses, including attorney's fees, which may be filed,
charged or adjudged against Maxicare or any of its directors, stockholders, officers, employees, agents, or
Representatives in connection with or arising from the use, processing and disclosure by Maxicare or its
Representatives of the aforementioned information pursuant to Maxicare's reliance on my and my dependent's
representation and warranty that Maxicare, the Company, and their representatives have the authority to examine, use,
process, store, share, or disclose, as the case may be, said information for the above-mentioned purposes.

7. Maxicare reserves the right to amend the Membership Terms and Conditions at any time without need of prior notice or
approval, and any queries related thereto may be addressed to DPO@maxicare.com.ph.

Very truly yours,

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2FA Confirmation Request ID
For Dependent of Legal Age: By affixing your signature below, you freely, knowingly and voluntarily given your
consent as described in this document.
Name Maxicare Membership No. Email Signature

EDDIE SIMBULAN TARUC

MYRA CAYABYAB TARUC

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