MAXICARE HEALTHCARE CORP.

COMPANY NAME Bluestyx Inc.

DATE

PRINCIPAL ENROLLEE/S
BRANCH/
RANK DATE OF BIRTH ROOM AND BOARD MAXIMUM BENEFIT PHILHEALTH
EMPLOYEE NO. CLASSIFICATION GENDER CIVIL STATUS (MM/DD/YYYY) PLAN TYPE CATEGORY LIMIT EFFECTIVITY DATE SITE/COST CENTER/ REQUEST TYPE NUMBER REMARK/S
AFFILIATE
LAST NAME FIRST NAME M.I EXTENSION NAME

Gold Regular Private 110,000.00 ADDL

Cont…

NAME OF PRINCIPAL DEPENDENT/S RELATIONSHIP TO

IF ENROLLING (Y/N) DATE OF BIRTH ROOM AND BOARD MAXIMUM BENEFIT PHILHEALTH
PRINCIPAL (E.G.
(state the reason if
spouse, child, parent, GENDER CIVIL STATUS (MM/DD/YYYY) PLAN TYPE CATEGORY LIMIT NUMBER
NOT enrolling)
LAST NAME FIRST NAME M.I EXTENSION NAME sibling etc.)

REQUEST TYPE:
ADDITIONAL [ ADDL] CHANGE OF STATUS [COS]
CANCELLATION/WITHDRAWAL [WD] CORRECTION [COR]
UPGRADING OF PLAN [UPG] TRANSFER [TRF]
DOWNGRADING OF PLAN [DWG] FIRST BATCH [FB]

“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.”

PREPARED BY: Kristel Gallego CERTIFIED BY: Lucita B. Dy CONTACT PERSON Kristel Gallego
Name and Designation Name and Designation Name and Designation