CERTIFICATION / SURVEY FORM

This form does not constitute an agreement to sign up

with MEDICard. It is merely a preliminary survey of
the health care needs of your company and authorizes
the MEDICard representative to transact exclusively
with you for the next 5 months.

DATE: March 17, 2011

ATTY JUAN ANDRES S. MONTOYA

Vice President – Marketing & Sales
MEDICard Philippines, Inc.
9th Floor, Sagittarius Bldg.,
H.V. dela Costa St., Salcedo Village,
Makati City

THRU: RICKY N. ROY

(MEDICard Representative)

I. This is to certify that our company Norbell Phils. 24/7 In-Touch Inc. is interested in a health care program for our
employees. We intend to have the program in place
immediately within the next 60 days within the next 6 months
II. We will be enrolling ___________60______ employees representing
(number of employees)

100% of our population top to middle management

rank and file other (selected personnel only)
III. We will also be enrolling ______________ dependents of our enrollees
(number of dependents)

100% of all eligible dependents of top/middle management only

1/2/3…dependents per employee other (selected dependents only)
IV. The benefits we wish to have in the program include

Hospitalization Out-patient Dental Benefit

Emergency Care Annual Physical Exam Members Financial Assistance
(employees only)

Additionally we request for:

Maternity __________________________________________________________
Medicine reimbursement _______________________________________________
Others (pls. specify) __________________________________________________

V. We have specific budget for the following plans:

A. Ward or Plan 450 – 650 PhP __________
B. Semi-Private or Plan 700 – 900 PhP __________
 C. Regular Private or Plan 1000 – 1400 PhP __________
D. Large Private or Plan 1500 and above PhP __________
VI. General Information

Full name of the company __Norbell Philippines 24/7 In-Touch Inc.

Complete address Beverly Place,Masamat, Mexico Pampanga
Nature of business Call Center
No. of years in operation 4 years
Telephone number +45-889-5989
Fax number _________________________________________________________________________
E-mail address _________________________________________________________________________
Proposal addressee Ms. Jenie D. Miranda
Designation Supervisor
Senior Officer(s) _________________________________________________________________________
Designation(s) _________________________________________________________________________
Holding
_______________________________________________________________
company/affiliates/subsidiaries
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Enrollees are covered under SSS/PhilHealth (formerly MEDICARE) Yes No

Classification of enrollees and number by level

Executive level _______________________________________________________________

Manager/Junior Executive _______________________________________________________________
Supervisional/Technical _______________________________________________________________
Rank & File _______________________________________________________________
Contractual, (if included in program) _______________________________________________________________

VII. Other company benefits (insurance, pension, retirement, etc.) are provided by _____________________________________
________________________________________________________________________________________________
The company utilizes the services of _____________________________________________________ brokerage company.
This includes health care. Yes No

BY:

_________________________________
SIGNATURE OVER PRINTED NAME

_________________________________
DESIGNATION/TITLE