MyHealth Insurance Details
All fields with asterisk marks (
*
) are required fields! Please make sure to fill them out!
Client Information
First Name
*
Middle Name
Last Name
*
Birthday
*
Gender
*
Civil Status
*
Mobile No.
*
Email Address
*
Plan Coverage (Hospital & Surgery)
*
Essential: $100,000
Essential: $500,000
Extensive: $1 million
Elite: $2 million
Area Coverage
*
Philippines and ASEAN countries excluding Singapore
Worldwide excluding USA
Worldwide
Optional Addons
Out-patient
Maternity
Dental & Optical
Optional Dependents
Dependent 1:
Gender
Age
Relation
Dependent 2:
Gender
Age
Relation
Dependent 3:
Gender
Age
Relation
Dependent 4:
Gender
Age
Relation
Dependent 5:
Gender
Age
Relation
Dependent 6:
Gender
Age
Relation
Additional Information
*
I authorize Synergen Insurance Agency, Inc. to use my personal information in accordance with the Data Privacy Act of 2012, its implementing rules and regulations, and the Synergen Insurance Agency, Inc.
Privacy Statement
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