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Before you proceed to the start with the enrollment of your dependents, we need your acknowledgement that you have carefully read the FY22 Renewal of HMO Services deck and other relevant links to guide you with the entire process. All the links on your email will provide you information about: (a) enhancements in our benefits, (b) the retained annual premium rates to be co-shared with the company, (c) enrollment hierarchy to follow, (d) required supporting documents for new enrollments and the (e) Pre-Termination agreement. HMO Dependent enrollment/ membership is an extension of your benefit as an active and regular employee of the company. Cancellations due to separations will automatically deactivate the membership of your dependent/s' account. Refund is not applicable for separations after more than 6 months of enrollment. If you missed the deck, you may still read and access the link here: FY22 HMO Enrollment Program. Please select applicable response below: Employee ID NumberPlease enter your office email address to receive a copy of the enrollment form.Last Name:Complete Name :Employee NameGiven Name:Complete Name :Employee NameMiddle Name:Complete Name :Employee NameMiddle Initial (M.I to use for card printing):Complete Name :Employee NameExt (Jr., II, etc.):Complete Name :Employee NameEmployee's Current Civil StatusEnrollment Classification(Enrollment classification will determine the available benefit plan options)Choose a Benefit Plan for your dependents(Remember that you may choose an equal or lower benefit plan)Choose a Benefit Plan for your dependents(Remember that you may choose an equal or lower benefit plan)Choose a Benefit Plan for your dependents(Remember that you may choose an equal or lower benefit plan)Choose a Benefit Plan for your dependents(Remember that you may choose an equal or lower benefit plan)Enrollment Eligibilities:Enrollment DetailsLast Name:Dependent 1:Dependent InformationGiven Name:Dependent 1:Dependent InformationMiddle Name:Dependent 1:Dependent InformationM.I. to Use:Dependent 1:Dependent InformationExt. (Jr., II, etc.):Dependent 1:Dependent InformationRelationship:Enrollment DetailsDate of Birth:Enrollment DetailsSex:Enrollment DetailsCivil Status:Enrollment DetailsDo you wish to enroll another dependent (2nd, in the hierarchy line)?:Enrollment DetailsEnrollment Eligibilities:Enrollment DetailsLast Name:Dependent 2:Dependent InformationGiven Name:Dependent 2:Dependent InformationMiddle Name:Dependent 2:Dependent InformationM.I. to Use:Dependent 2:Dependent InformationExt. (Jr., II, etc.):Dependent 2:Dependent InformationRelationship:Enrollment DetailsDate of Birth:Enrollment DetailsSex:Enrollment DetailsCivil Status:Enrollment Details
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Yes - I have read the deck and relevant links about the FY22 HMO Enrollment Program.1234me1234@yahoo.comAlivarezRanzAngelesiASingleDependents of Supervisor | SpecialistRegular Private | 250,000.00[Immediate Dependent] Single, enrolling parent/s, child/ren and siblingsAlivarezFazimaAngelesiAMother10/14/1966FemaleMarriedYes[Immediate Dependent] Single, enrolling parent/s, child/ren and siblingsAlivarezMia FortunaAngelesiASister1/5/2004FemaleSingle
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Yes - I have read the deck and relevant links about the FY22 HMO Enrollment Program.2468elias6789@yahoo.comNablosVincentGuccenaGSingleDependents of Supervisor | SpecialistRegular Private | 150,000.00[Immediate Dependent] Single, enrolling parent/s, child/ren and siblingsNablosAsuncionaGuccenaGMother8/14/2021FemaleWidow/WidowerNo
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Yes - I have read the deck and relevant links about the FY22 HMO Enrollment Program.3690yeahboy@yahoo.comJordanDanvieLucenaBSingleDependents of Supervisor | SpecialistRegular Private | 150,000.00
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Yes - I have read the deck and relevant links about the FY22 HMO Enrollment Program.1089gandaghorl@yahoo.comMaharlikaDhannieMayZSingleDependents of Supervisor | SpecialistRegular Private | 350,000.00[Immediate Dependent] Single, enrolling parent/s, child/ren and siblingsMaharlikaSeantiDeannaDFather4/25/1958MaleMarriedYes[Immediate Dependent] Single, enrolling parent/s, child/ren and siblingsMaharlikaDharling ErikaMayZSister5/4/2013FemaleSingle
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