HMO Dependent Enrollment - Field Office I

Lets field office staff add a family dependent to the company health plan. It gathers details for both the dependent and the principal member, the relationship between them, the chosen payment method and the signed deduction authorisation. Built for benefits and payroll administrators.

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Employee ID number*

Dependent's name*

Nombre

Apellido

Dependent's sex*

Female Male

Dependent's date of birth*

Dependent's civil status*

Single Married Widowed Separated

Relationship to the principal member*

Spouse Child Parent Sibling

Principal member's name*

Nombre

Apellido

Principal member's date of birth*

Principal member's sex*

Female Male

Principal member's civil status*

Single Married Widowed Separated

Employment status*

Permanent Probationary Contractual Part time

Date of appointment*

Contact number*

Email address*

Mode of payment*

Salary deduction Bank transfer Cash Cheque

Upload the scanned authority to deduct or commitment to pay form*

Max 10 MB per file

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