MAXICARE HEALTHCARE CORP.

Company Name:Date:

EMPLOYEE NO. PRINCIPAL ENROLLEE/S

LAST NAME FIRST NAME

REQUEST TYPE:ADDITIONAL [ ADDL]CANCELLATION/WITHDRAWAL [WD]UPGRADING OF PLAN [UPG]DOWNGRADING OF PLAN [DWG]

PREPARED BY:

“I hereby certify that the above information given are true and correct. In case any of the above information is found to be false or untrue or misleading or misrepresenting, Maxicare Healthcare Corporation has the right to immediately terminate the agreement.”

RANK CLASSIFICATION GENDER CIVIL STATUS

M.I EXTENSION NAME

CHANGE OF STATUS [COS]CORRECTION [COR]TRANSFER [TRF]FIRST BATCH [FB]

CERTIFIED BY:(CONTACT PERSON)

I hereby certify that the above information given are true and correct. In case any of the above information is found to be false or untrue or misleading or misrepresenting, Maxicare Healthcare Corporation has the right to immediately terminate the agreement.”

PLAN TYPEDATE OF BIRTH (MM/DD/YYYY)

ROOM AND BOARD

CATEGORYMAXIMUM BENEFIT

LIMIT

I hereby certify that the above information given are true and correct. In case any of the above information is found to be false or untrue or misleading or misrepresenting, Maxicare Healthcare Corporation has the right to immediately terminate the agreement.”

EFFECTIVITY DATE REQUEST TYPE REMARK/S

LAST NAME

BRANCH/SITE/COST CENTER/AFFILIATE

NAME OF PRINCIPAL DEPENDENT/S

FIRST NAME M.I EXTENSION NAME

IF ENROLLING (Y/N) (state the reason if

NOT enrolling)

RELATIONSHIP TO PRINCIPAL (E.G.

spouse, child, parent, sibling etc.)

GENDER CIVIL STATUS PLAN TYPEDATE OF BIRTH (MM/DD/YYYY)

ROOM AND BOARD

CATEGORYMAXIMUM BENEFIT

LIMIT