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    Statement of Lost ID Form

    Uploaded by

    Arianne Laydia
    This document is a statement of lost ID card from Maxicare Healthcare Corporation. It provides information for a member to declare that their Maxicare ID card was lost and request a replacement. The member must provide their name, employee number, date of birth, and contact details. They must pay a fee for the new ID card and submit the signed statement along with proof of payment and valid ID to their HR or Maxicare representative. The new ID card will be issued within 5 days once all documentation is received.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Statement of Lost ID Form

    Uploaded by

    Arianne Laydia
    187 views1 page
    This document is a statement of lost ID card from Maxicare Healthcare Corporation. It provides information for a member to declare that their Maxicare ID card was lost and request a replacement. The member must provide their name, employee number, date of birth, and contact details. They must pay a fee for the new ID card and submit the signed statement along with proof of payment and valid ID to their HR or Maxicare representative. The new ID card will be issued within 5 days once all documentation is received.

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    This document is a statement of lost ID card from Maxicare Healthcare Corporation. It provides information for a member to declare that their Maxicare ID card was lost and request a replacement. The member must provide their name, employee number, date of birth, and contact details. They must pay a fee for the new ID card and submit the signed statement along with proof of payment and valid ID to their HR or Maxicare representative. The new ID card will be issued within 5 days once all documentation is received.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    187 views1 page

    Statement of Lost ID Form

    Uploaded by

    Arianne Laydia
    This document is a statement of lost ID card from Maxicare Healthcare Corporation. It provides information for a member to declare that their Maxicare ID card was lost and request a replacement. The member must provide their name, employee number, date of birth, and contact details. They must pay a fee for the new ID card and submit the signed statement along with proof of payment and valid ID to their HR or Maxicare representative. The new ID card will be issued within 5 days once all documentation is received.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    MAXICARE HEALTHCARE CORPORATION

    Maxicare Tower 203 Salcedo Street Legaspi Village, Makati City


    Telephone: 908-6900; Customer Care Hotline: 582-1900

    STATEMENT OF LOST ID CARD

    KNOW ALL MEN BY THESE PRESENTS:

    THAT I,_____________________________ of______________________________ having an interest in a


    contract of MAXICARE HEALTHCARE CORPORATION with the following data:

    Name of Member(s) subject for ID card replacement


    Applicable Employee No.
    Date of Birth
    Contact/Mobile Number:
    Email Address:

    Issued by MAXICARE HEALTHCARE CORPORATION, do hereby manifest and present that the
    said ID CARD issued in my favor was lost and could not be located despite diligent efforts to retrieve
    the same.

    I HEREBY DECLARE that my interest in the said ID CARD has not been sold or transferred to any
    person and the absolute title of full benefits in said ID CARD remains in me.

    I HEREBY AGREE to pay an amount equivalent to P_____ to MAXICARE HEALTHCARE


    CORPORATION as payment for the new ID CARD.

    Signed at ______________ this ____day of ________. August 2014.

    _____________________________________
    SIGNATURE OF MEMBER
    SIGNED IN THE PRESENCE OF

    _______________________________________ _________________________________________
    Print Name and Signature Print Name and Signature

    Note: Please submit VALID PROOF OF PAYMENT with NOTARIZED AFFIDAVIT OF LOSS/ OR
    VALID ID WITH PICTURE together with the STATEMENT OF LOST ID CARD to your HR or
    authorized Maxicare representative. You may pay through the following payment channels:

    Payment Type Payment Channels


    Direct Payment Cashier at Maxicare Tower
    Online/Internet Payment BDO, BPI, Equicom Bank, Metrobank, PNB, RCBC, Unionbank
    Bills Payment Over the BDO, BPI, Equicom Bank, Metrobank, PNB (original branches only), RCBC,
    counter Payment Security Bank, Unionbank and CIS Bayad Center
    Note: For Online and Bills Payment, please indicate MAXICARE under Company Name

    You may coordinate to Maxicare Cashier or Account Management Representatives for the copy of your
    official receipt. New ID cards will be released within five (5) working days after submission of complete
    requirements to Maxicare Head Office.

    Form Template Control: Underwriting and Enrollment Fulfillment/May15, 2018/FO-UEF-0.010 /Rev.02

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