Corporate HMO Assessment Form There was an error trying to submit your form. Please try again.Section 1: Company Information Company Name * This field is required. Industry * Select an optionBPO / Call CenterConstruction / EngineeringEducation / TrainingFinancial Services / InsuranceFood & Beverage / RestaurantHealthcare / MedicalHospitality / Hotel / ResortInformation Technology / SoftwareLegal ServicesLogistics / TransportationManufacturing / ProductionMarketing / Advertising / PRNon-Government Organization (NGO)Pharmaceutical / Life SciencesReal Estate / Property ManagementRetail / Wholesale / DistributionSecurity ServicesTelecommunicationsUtilities / Energy / WaterCooperative / Association / UnionOthers This field is required. If "Others", input your Industry here This field is required. Completee Business Address Address * This field is required. Barangay * This field is required. City * This field is required. Region * This field is required. Postal Code This field is required. Country * This field is required. Total No. of Employees * Less than 10 employees 11 to 50 employees 51 to 100 employees 101 to 200 employees 201 to 300 employees 301 to 400 employees 401 - 500 employees More than 500 employees This field is required.Section 2: Contact Person Full Name * This field is required. Position or Role * This field is required. Email Address * This field is required. Active Mobile Number * This field is required.Section 3: Employee Coverage Preferences Which employee types do you want to cover? (Select all that apply) * Rank-and-file Supervisors Managers Executives Probationary or Contractual Staff This field is required. Preferred Coverage Start Date (mm/dd/yyyy): * This field is required.Section 4: Budget & Benefits Estimated Monthly Budget per Employee (₱): * Select an option< ₱500₱500-₱999₱1,000–₱1,500₱1,500–₱2,000₱2,000+ This field is required. Preferred Type of Plan: (Select all that apply) * Inpatient (Hospitalization) Outpatient (Consultation, Labs) Emergency Care Dental Annual Physical Exams (APE) PEC Coverage Others This field is required. For 'Others', input here This field is required.Section 5: Additional Concerns / Preferences Access to hospitals/clinics/doctors * Select an optionNationwideNCR onlyLuzon (except NCR)Visayas & Mindanao Only This field is required. Access to specific hospitals or clinics? This field is required. Existing HMO Provider (if any) This field is required. End Date (mm/dd/yyyy) This field is required. Past challenges with previous HMO provider? Other preferences or comments: We’ll review your answers and get in touch within 1–2 working days to schedule a consultation and send a customized HMO proposal. I consent Pinoy Insure to store my submitted information so they can respond to my inquiry. * This field is required. Submit There was an error trying to submit your form. Please try again.
