I CARE QUOTATION FORM (Individual/Family Plan)
Thank you for your interest in I CARE services. For us to give you the best, please provide us with the following information. Items marked with a red arrow are required fields.
Your Name
Your E-mail
Address
Tel. No.
Cellular Phone No.
Civil Status
Married
Single
Widow/er
Divorced/Separated
Date of Birth
Age of spouse (n/a if single)
Number of Dependents(n/a if none)
Ages of Dependents (please separate with(n/a if none)
Preferred Plan
Suite
Semi-Private
Private
Preferred Hospital
Do you have an existing Health Care Plan
Yes
No
If yes, what HMO provider?
What Plan?
