Individual or Family HMO Assessment Form There was an error trying to submit your form. Please try again.Section 1: Contact Person Full Name * This field is required. Email Address * This field is required. Active Mobile Number * This field is required.Section 2: Budget & Benefits Preferences Plan Type * Select an optionPersonalFamily This field is required. If opted for a Family plan, how many dependents will be enrolled? This field is required. Estimated Monthly Budget per Member (₱): * 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 3: 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.
