Scribd
Upload
83 views1 page

Room & Board Maximum Benefit Limit (PHP) Annual Premium (PHP) Room & Board Maximum Benefit Limit (PHP) Annual Premium (PHP)

This document is an enrollment form for the MediCard health insurance plan provided by Census Provident Fund, Inc. It lists the room and board benefit limits and annual premiums for ward, semi-private, small private, and large private hospital rooms. The enrollee agrees to make a one-time full premium payment, have the PhP1,500 health care assistance waived but deducted from their premium, and enroll in a special loan program to repay any balance through monthly salary deductions at 5% annual interest.

Uploaded by

erap0217
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
83 views1 page

Room & Board Maximum Benefit Limit (PHP) Annual Premium (PHP) Room & Board Maximum Benefit Limit (PHP) Annual Premium (PHP)

This document is an enrollment form for the MediCard health insurance plan provided by Census Provident Fund, Inc. It lists the room and board benefit limits and annual premiums for ward, semi-private, small private, and large private hospital rooms. The enrollee agrees to make a one-time full premium payment, have the PhP1,500 health care assistance waived but deducted from their premium, and enroll in a special loan program to repay any balance through monthly salary deductions at 5% annual interest.

Uploaded by

erap0217
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 1

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

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy