Hoatthglis cece EMPLOYEE PROFILE FORM | Pat cate , sun Eros Tine Feeney ‘SECTION DEPENDANT NFORNATON (FOR DEPENDANT COVERAGE ONL) IC /9C/FNN, Naty Sint Bain Rae tai ce) ame ea ies amity coupon wena Peng Patan, Paging Fila sey Compan egns Eetharuonet oe ean eee he sty oer = =— nay e624 O68, Abra yu oul nd oo by ptt a ave ansDear Employee, TERMS & CONDTIONS [ACKNOWLEDGEMENT FORM ‘We are pleased to be given the riage to meet your healncare needs through the IMP HoothPlue Plan and to present you your personal IP identiiestion card. To actvate the lise of your card, we would sppredata ff you could read the folowing terms. and ‘condone of fhe Plan and sign fn the space provided below We look foward to be of senves fo you Thank you INTEGRATED HEALTH PLANS PTE LTD Terms & Conions ‘The FP HealthPlus identscaon card is nt tansterabl. ‘The card must be presented belore modal services can be rendered, [MP Ple Lid reserves the righ lo reluse the use ofthis car. Loss of this card should be reported tothe cardholders employer immediately. An _administation foe of $5.25 (neusive 8% GST) will bo imposed for replacement of fost ears ‘Tie ca is the property of Integrated Heath Plans Pte Lid. |HP ie authorized to communicate with IP participating doctors, fects andthe ‘cardholder's employer on modiel information pertaining o any Westment obtained bythe cardholder under the IMP Plan Al information fs held strictly confidential Employee: \ uc Ho. 2, 2900s tthe ‘Spats Toe ‘Canpany Nae Dependant(s) (applicable): ' __(nricno, ).2gres tote ‘nr and conan wate above on bata omy dopendois Nee INRIC/ BC Ne. t _ 5 ——————r 2 ‘SignatweTOaie ‘Wetec