Insuring Your Peace of Mind

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PERSONAL & FAMILY HEALTHCARE FORM

First Name: *

Middle Name:

Family Name: *

Suffix: *

Birthdate: *

Person below 18 yrs old not qualified

Sex: *

Nationality *

Civil Status *

Height(ft/in.):

Weight(kg):

Place of Birth:

Email Address:

Contact Number:

Present Address (Unit/Bldg., Number, Street, Subdivision, Barangay): *

City *

State/Province *

CheckboxCheck if the Present Address is the same as Permanent Address

Permanent Address (Unit/Bldg., Number, Street, Subdivision, Barangay): *

City *

State/Province *

SSS: *

TIN: *

Nature of Work: *

Occupation: *

Group/Corporate Name: *

Type of Plan(I)NDIVIDUAL(F)AMILY

Plan Type: *

Document Type *

Government ID *

No file chosen

Only jpg, png, pdf formats are allowed to max size of 20 MB

I.D. Number *

Insurance Dependents

Dependent's Name: *

Relationship: *

Birthdate: *

Upload Valid ID *

No file chosen

Medical Information (Principal)

1. Have you ever been treated for or ever had any known indication of:

a. Disorder of eyes, ears, nose, or throat?YesNo

b. Dizziness, fainting, convulsions, headache, speech defect, paralysis or stroke, mental or nervous disorder?YesNo

c. Shortness of breath, persistent hoarseness or cough, blood-spitting bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic respiratory disorder?YesNo

d. Chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack or any other disorders of the heart or blood vessels?YesNo

e. Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, diverticulitis colitis, hemorrhoids, recurrent indigestion, or other disorders of the stomach, intestines, liver or gallbladder?YesNo

f. Sugar, albumin, blood or pus in urine, venereal disease, stone or other disorders of kidney, bladder, prostate or reproductive organs?YesNo

g. Diabetes thyroid or other endocrine disorders?YesNo

h. Neuritis, sciatica, rheumatism, arthritis, gout, or disorder of the muscles or bones, such as spine, back or joints?YesNo

i. Deformity, lameness or amputation?YesNo

j. Disorder of skin, lymph glands, cysts, tumor or cancer?YesNo

k. Allergies, anemia or other disorders of the blood?YesNo

l. Excessive use of alcohol, tobacco or any habit-forming drugs?YesNo

2. Are you now under observation or taking treatment?YesNo

3. Do you smoke cigarette?YesNo

4. Other than above, have you:

a. Had any physical disorder or any known indication thereof?YesNo

b. Had a medical examination, consultation, illness, injury, surgery?YesNo

c. Been a patient in a hospital, clinic, sanitarium, or other medical facility?YesNo

d. Had electrocardiogram, x-ray, other diagnostic tests?YesNo

e. Been advised to have a diagnostic test, hospitalization, or surgery which was not completed?YesNo

5. Have you ever had military service deferment, rejection or discharge because of physical or mental condition?YesNo

6. Have you ever applied for or received a pension, payment, or benefit due to injury, sickness or disability?YesNo

7. Have you a parent, brother, sister who died of or had high blood pressure, tubercolosis, diabetes, cancer, heart or kidney disease, or mental illness?YesNo

8. FOR FEMALES ONLY:

a. Have you ever had any abnormal menstruation, pregnancy, childbirth or disorder of the female organs or breast?YesNo

b. Are you now pregnant?YesNo

c. Are you taking contraceptives pills?YesNo

9. Have you ever been rejected or terminated for medical insurance including Rayocare program, or have been offered insurance at a higher (rated-up) premium?YesNo

Consent *

In compliance with Republic Act 10173 also known as the Data Privacy Act of 2012; We need your consent to allow us to collect and process your information. We will only disclose and share your information with our accredited health care providers who may also be responsible in rendering our services to you.
Withholding or withdrawal of such Consent shall relieve us from our obligation to deliver the appropriate services to you.

You are afforded with certain rights and protection in accordance with the said Act. Visit www.RayomarInsuranceBusiness.com/privacy for more information.

By ticking the box, we will consider that you agree to give your Consent, privacy policy and terms and conditions to us.

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Business Hours: 8:00AM to 5:00PM | Mondays to Fridays
6F Country Space 1 Bldg., H.V Dela Costa St., Makati City
Tel: 8801-9912 | 8801-9915
Email: [email protected]