AYOS HEALTH CARD 2.0
APPLICANT DECLARATION, PAYMENT TERMS & CONSENT
IMPORTANT — PLEASE READ CAREFULLY BEFORE SUBMITTING
AYOS Health Card 2.0 uses an automated medical underwriting assessment based on the answers and medical declarations provided in this application.
Your answers to the Medical Underwriting Questionnaire may affect your applicable premium. It is therefore important that all medical information requested in this application is completely, truthfully, and accurately disclosed.
PLEASE REVIEW ALL INFORMATION CAREFULLY BEFORE SUBMITTING. ONCE YOUR APPLICATION IS SUCCESSFULLY SUBMITTED TOGETHER WITH THE REQUIRED PROOF OF PAYMENT AND PROCESSING HAS COMMENCED, IT WILL BE TREATED AS FINAL AND ENDORSED FOR PAYMENT VERIFICATION, ENROLLMENT, UNDERWRITING VALIDATION, AND ACTIVATION PROCESSING.
1. FINAL PREMIUM & PAYMENT TERM
Your applicable premium is automatically determined based on your selected plan and the information declared in the Medical Underwriting Questionnaire.
Where applicable, the system will automatically apply the corresponding Medical Underwriting Multiplier / Premium Loading based on your declared medical condition/s.
The premium displayed upon completion of this application is considered your Final Premium based on the information you have declared and your selected payment term.
The available payment terms are:
Annual Payment — the applicable Annual Premium is paid in full.
Semi-Annual Payment — the premium is payable in two (2) scheduled installments. A 10% modal surcharge applies to the Annual Premium when the Semi-Annual Payment Option is selected.
Semi-Annual Premium Computation
For applicants who select the Semi-Annual Payment Option, a 10% modal surcharge shall be applied to the applicable Annual Premium.
The Semi-Annual installment shall be calculated as follows:
Annual Premium × 110% ÷ 2 = Semi-Annual Premium per installment
This is equivalent to:
Annual Premium × 55% = Semi-Annual Premium per installment
Example
If the applicable Annual Premium is ₱18,888.00:
₱18,888.00 × 110% = ₱20,776.80
Total premium obligation under the Semi-Annual Payment Option:
₱20,776.80
Divided into two (2) installments:
1st Semi-Annual Premium: ₱10,388.40
2nd Semi-Annual Premium: ₱10,388.40
Accordingly, the total premium payable under the Semi-Annual Payment Option is 10% higher than the applicable Annual Premium due to the modal surcharge.
The amount displayed as the Initial Premium Due represents the first Semi-Annual installment required to process the application and commence coverage, subject to payment verification, activation requirements, underwriting provisions, and the applicable AYOS Health Card Terms & Conditions.
Payment of the first Semi-Annual installment does not constitute full payment of the premium obligation for the entire plan period.
The applicant/member remains responsible for paying the succeeding Semi-Annual Premium on or before its applicable due date in order to maintain continuous coverage for the remainder of the plan period.
Once you proceed with payment, no separate Counter-Offer Letter is required for the premium displayed in this application.
Official Payment Details
Bank Name: BDO (Banco de Oro)
Account Name: IOSS Insurance Agency Inc.
Account Number: 0128 5800 3683
⚠️ IMPORTANT PAYMENT NOTICE
Payments must be made exclusively to the official company bank account stated above.
IOSS Insurance Agency Inc. shall not be held liable for payments made to unauthorized accounts or individuals.
A valid and readable Proof of Payment must be uploaded before submitting this application.
Please ensure that the amount paid corresponds to the premium amount currently due and indicated in your application based on your selected payment term.
Applicants are responsible for reviewing the payment amount, selected payment term, and information entered in the application before submission.
2. SEMI-ANNUAL PAYMENT OBLIGATION, MODAL SURCHARGE, NON-PAYMENT & TERMINATION
If I select the Semi-Annual Payment Option, I acknowledge and agree that:
A 10% modal surcharge is applied to my applicable Annual Premium;
The resulting premium is divided into two (2) Semi-Annual installments;
Each Semi-Annual installment is equivalent to 55% of the applicable Annual Premium, subject to rounding where applicable;
The total of the two (2) Semi-Annual installments is equivalent to 110% of the applicable Annual Premium;
Payment of the first Semi-Annual installment does not constitute full payment of the premium obligation for the entire plan period; and
I am responsible for paying the succeeding Semi-Annual Premium on or before its applicable due date.
I understand that choosing the Semi-Annual Payment Option is a payment arrangement and that the applicable 10% modal surcharge forms part of my total premium obligation.
⚠️ IMPORTANT — FAILURE TO PAY SUCCEEDING PREMIUM
FAILURE TO FULLY SETTLE THE SUCCEEDING SEMI-ANNUAL PREMIUM WITHIN THE APPLICABLE PAYMENT PERIOD SHALL RESULT IN THE TERMINATION OF THE AYOS HEALTH CARD PLAN, SUBJECT TO THE APPLICABLE TERMS & CONDITIONS.
Upon the effective termination of the plan due to non-payment:
The member's AYOS Health Card coverage and benefits shall cease in accordance with the applicable Terms & Conditions;
No further benefits or coverage shall be available for healthcare services, confinement, treatment, procedures, claims, or expenses incurred after the effective date of termination;
IOSS Insurance Agency Inc. / AYOS Health Card shall not be liable for claims, benefits, medical expenses, or healthcare costs incurred after the effective termination of coverage due to non-payment of the required succeeding premium, subject to applicable law and the AYOS Health Card Terms & Conditions; and
Any reinstatement, reapplication, or continuation of coverage, if permitted, shall be subject to the applicable rules, requirements, underwriting guidelines, and Terms & Conditions then in effect.
The applicant/member is responsible for monitoring and settling the succeeding premium when due.
Any payment reminder provided by IOSS Insurance Agency Inc. / AYOS Health Card is a courtesy and does not relieve the applicant/member of the responsibility to pay the required premium on time.
Nothing in this provision is intended to exclude or limit any liability, benefit, claim, or remedy that cannot lawfully or contractually be excluded, including any valid benefit or claim arising during a period when coverage was still in force, subject to the applicable AYOS Health Card Terms & Conditions.
3. PAYMENT VERIFICATION, 15-DAY ACTIVATION & NON-CANCELLATION
Please allow approximately 2–3 banking days for payment posting and verification.
Once your payment has been successfully posted and verified, a confirmation will be sent to your registered email address from:
[email protected]
Your Verified Payment Date shall serve as the basis for the start of your 15-day activation period.
Your AYOS Health Card shall become activated and available for use fifteen (15) calendar days from the Verified Payment Date, subject to applicable benefit-specific waiting periods, exclusions, limitations, payment requirements, and other provisions of the AYOS Health Card Terms & Conditions.
For members who select the Semi-Annual Payment Option, activation following verification of the initial premium does not waive the obligation to pay the succeeding premium when due.
Example
If your payment is successfully verified on September 5, your 15-day activation period will begin counting from September 5.
The date you initially submitted the application or transferred your payment does not determine the activation period if the payment has not yet been successfully posted and verified.
⚠️ IMPORTANT — FINAL SUBMISSION & NON-CANCELLATION
Please review your entire application carefully before clicking SUBMIT APPLICATION.
Once this application has been successfully submitted together with the required Proof of Payment, the application shall be considered final and endorsed for payment verification, enrollment, underwriting validation, and activation processing.
Accordingly, requests for voluntary cancellation, withdrawal, reversal, or refund due solely to a change of mind shall no longer be accepted once the application has been submitted and processing has commenced, subject to applicable laws, regulations, contractual provisions, and the AYOS Health Card Terms & Conditions.
Applicants are therefore strongly advised to verify the following BEFORE SUBMISSION:
Selected AYOS Health Card plan and Maximum Benefit Limit (MBL);
Selected payment term — Annual or Semi-Annual;
Member and personal information;
Medical declarations and answers to the Medical Underwriting Questionnaire;
Final Premium displayed in the application;
Amount currently due and payment details;
For Semi-Annual payments, the applicable 10% modal surcharge;
For Semi-Annual payments, the obligation to settle the succeeding premium when due; and
Applicable benefits, exclusions, waiting periods, limitations, and Terms & Conditions.
By submitting the application, the applicant authorizes IOSS Insurance Agency Inc. / AYOS Health Card and its authorized partners to proceed with payment verification, enrollment, underwriting validation, and activation processing.
This non-cancellation provision does not prevent any cancellation, refund, correction, or other remedy that may be required under applicable law, applicable AYOS Health Card Terms & Conditions, or due to circumstances attributable to IOSS Insurance Agency Inc., AYOS Health Card, or its authorized partners.
4. AUTOMATED MEDICAL UNDERWRITING
Your application is automatically assessed for medical underwriting based on the answers and medical declarations you provide in the Medical Underwriting Questionnaire.
Depending on your declared medical condition/s, the system may automatically determine the applicable:
Disclosure of a medical condition does not automatically mean that your application will be declined.
Where applicable, Premium Loading is already incorporated into the Final Premium displayed in your application.
If the Semi-Annual Payment Option is selected, the applicable 10% modal surcharge is applied in addition to the applicable premium and any Medical Underwriting Multiplier/Premium Loading reflected in the computation.
You are therefore responsible for carefully reviewing all answers, medical declarations, selected payment term, applicable modal surcharge, and premium due before submitting the application and completing payment.
The automated underwriting result is based on the information provided by the applicant and remains subject to applicable underwriting guidelines, verification requirements, Terms & Conditions, and applicable laws and regulations.
5. COMPLETE & ACCURATE MEDICAL DISCLOSURE
By submitting this application, I declare that all information, answers, selections, documents, and medical declarations I have provided are true, complete, correct, and accurate to the best of my knowledge.
I understand that I am required to disclose all medical information specifically requested in the application and Medical Underwriting Questionnaire, including, where applicable:
Known Pre-Existing Conditions (PECs);
Current and previous illnesses or diagnoses;
Persistent, recurring, unexplained, or unresolved symptoms;
Hypertension, diabetes, kidney, heart, lung, neurological, and other medical conditions;
Tumor, mass, new growth, or cancer, where specifically asked in the Medical Underwriting Questionnaire;
Physical injuries or deformities;
Medical consultations and follow-ups;
Prescription and maintenance medications;
Laboratory and diagnostic examinations;
Abnormal or unresolved medical findings;
Emergency room visits and outpatient treatments;
Hospitalizations;
Surgeries and medical procedures;
Recommended, scheduled, postponed, or pending procedures;
Pending medical tests, investigations, biopsies, or referrals;
Ongoing treatment, rehabilitation, or therapy; and
Other health or medical information specifically requested in this application.
I understand that answering “NO,” “NONE,” or leaving a listed medical condition unselected represents my declaration that, to the best of my knowledge, the applicable condition or circumstance does not apply to me.
I understand that the accuracy and completeness of my declarations are material to the underwriting assessment, premium determination, eligibility, and administration of my AYOS Health Card coverage.
6. UNDECLARED PEC, CONCEALMENT & MISREPRESENTATION
I understand that the Final Premium and underwriting result generated by this application are based on the medical information I declare.
I acknowledge that I must disclose any known Pre-Existing Condition (PEC) or other material medical information specifically requested in this application.
Failure to disclose a known PEC or other material medical information may be considered concealment, material non-disclosure, omission, or misrepresentation, where applicable.
If it is subsequently established that a known medical condition or material medical information that should have been disclosed was intentionally or materially withheld, the consequences may include, subject to applicable Terms & Conditions, underwriting guidelines, contractual provisions, and applicable laws:
Exclusion of the undeclared or affected medical condition from coverage;
Adjustment or reassessment of applicable coverage or underwriting terms;
Denial or non-payment of claims or benefits relating to the undeclared condition where permitted;
Recovery of benefits improperly obtained as a result of material fraud or misrepresentation; and/or
Cancellation, rescission, or termination of the AYOS Health Card plan where legally and contractually permitted.
Payment of the applicable premium and activation of the AYOS Health Card do not waive the applicant's responsibility to provide complete and truthful medical information.
If I realize before activation that I have omitted, incorrectly answered, or failed to disclose any medical information requested in this application, I agree to immediately notify AYOS Health Card / IOSS Insurance Agency Inc.
I understand that notification of an incorrect or omitted declaration does not automatically guarantee that the original premium, underwriting result, or coverage terms will remain unchanged.
Where applicable, the application may be reviewed or reassessed in accordance with applicable underwriting guidelines and Terms & Conditions.
7. AUTHORIZATION, DATA PRIVACY & INFORMATION PROCESSING
By submitting this application, I authorize IOSS Insurance Agency Inc. / AYOS Health Card and its duly authorized HMO, insurance, medical, underwriting, administrative, technology, and service partners to collect, process, validate, verify, store, and use my personal and sensitive personal information as reasonably necessary for:
Application and enrollment processing;
Identity and eligibility verification;
Automated and/or medical underwriting;
Risk assessment;
Premium determination and Premium Loading;
Administration and servicing of coverage;
Healthcare benefit coordination;
Claims and utilization evaluation;
Customer and member support;
Fraud prevention, detection, and investigation; and
Legal, regulatory, audit, and compliance requirements.
This may include my identification and contact information, HMO information, medical history, diagnoses, symptoms, medications, consultations, laboratory and diagnostic information, hospitalization and surgical history, medical records, and supporting documents.
I understand that additional information, clarification, medical records, or authorization may still be requested where reasonably necessary for enrollment, servicing, claims evaluation, verification, fraud investigation, or compliance purposes.
My personal and sensitive personal information will be handled in accordance with applicable privacy laws and regulations, including the Data Privacy Act of 2012 (Republic Act No. 10173), its implementing rules and regulations, and applicable privacy policies.
8. MARKETING COMMUNICATIONS
I acknowledge that my name, email address, and mobile/contact number may be used by IOSS Insurance Agency Inc. / AYOS Health Card, subject to applicable consent and data privacy requirements, for customer communications and optional marketing communications relating to:
AYOS Health Card products and services;
Benefits and healthcare-related offerings;
Promotions and events;
Renewal and premium payment reminders; and
Other products or services offered or distributed by IOSS Insurance Agency Inc. / AYOS Health Card.
Communications may be sent through permitted channels including email, SMS/text message, and telephone call.
Where applicable, I may opt out of optional marketing communications. Opting out will not affect necessary communications relating to my application, membership, benefits, premium payments, activation, or coverage.
9. TERMS & CONDITIONS & ELECTRONIC SUBMISSION
View Full Schedule of Benefits and Terms and Conditions Here.
I confirm that I have been provided access to the official AYOS Health Card Terms & Conditions and applicable Schedule of Benefits, including applicable:
Benefits and coverage limits;
Pre-Existing Condition coverage;
Exclusions and limitations;
Waiting periods;
Medical underwriting provisions;
Premium Loading provisions;
Annual and Semi-Annual payment provisions, where applicable;
10% modal surcharge applicable to the Semi-Annual Payment Option;
Consequences of non-payment of a succeeding premium; and
Coverage, activation, and termination rules.
I acknowledge that I am responsible for reviewing these documents before submitting my application.
NO PHYSICAL SIGNATURE REQUIRED
This application is completed and submitted electronically. No separate handwritten, wet, or physical signature is required.
By clicking SUBMIT APPLICATION and successfully submitting this form, I confirm and acknowledge that:
I have read and understood the information and provisions presented in this application;
All information and medical declarations I provided are true, complete, and accurate to the best of my knowledge;
I understand that my answers to the Medical Underwriting Questionnaire are automatically assessed and may affect my applicable premium;
I understand that the premium displayed in this application is my Final Premium based on my declarations and selected payment term;
I understand that where applicable, any Medical Underwriting Multiplier or Premium Loading has already been incorporated into the applicable premium;
I understand that I may select an Annual or Semi-Annual Payment Option, where available;
If I select the Semi-Annual Payment Option, I understand that a 10% modal surcharge applies to my applicable Annual Premium;
I understand that each Semi-Annual installment is equivalent to 55% of my applicable Annual Premium, subject to rounding where applicable;
I understand that the combined amount of my two Semi-Annual installments is equivalent to 110% of my applicable Annual Premium;
I understand that the Semi-Annual Payment Option therefore results in a higher total premium than paying the applicable Annual Premium in full;
I understand that payment of the first Semi-Annual Premium does not constitute full payment for the entire plan period and that I remain responsible for paying the succeeding premium when due;
I understand that failure to settle the succeeding Semi-Annual Premium within the applicable payment period may result in termination of my AYOS Health Card plan in accordance with the applicable Terms & Conditions;
I understand that following the effective termination of coverage due to non-payment, IOSS Insurance Agency Inc. / AYOS Health Card shall not be liable for claims, benefits, medical expenses, or healthcare costs incurred after the effective termination date, subject to applicable law and Terms & Conditions;
I understand that my 15-day activation period starts from the Verified Payment Date;
I understand my responsibility to disclose all known PECs and other medical information specifically requested in this application;
I understand that material concealment, non-disclosure, omission, falsification, or misrepresentation may result in exclusion of an affected condition, denial of an affected claim, and/or cancellation, rescission, or termination of coverage where permitted;
I understand that once I successfully submit this application together with the required Proof of Payment, my application will be considered final and will proceed for payment verification, enrollment, underwriting validation, and activation processing;
I understand that requests for voluntary cancellation, withdrawal, reversal, or refund due solely to a change of mind will no longer be accepted once my application has been submitted and processing has commenced, subject to applicable laws, regulations, contractual provisions, and the AYOS Health Card Terms & Conditions;
I confirm that before submitting, I have reviewed my selected plan, payment term, personal information, medical declarations, Final Premium, applicable modal surcharge, amount currently due, payment details, benefits, exclusions, waiting periods, limitations, and applicable Terms & Conditions;
I expressly authorize IOSS Insurance Agency Inc. / AYOS Health Card and its authorized partners to proceed with payment verification, enrollment, underwriting validation, and activation processing upon submission;
I authorize the collection and processing of my information as described above; and
I acknowledge and agree to the applicable AYOS Health Card Terms & Conditions and Schedule of Benefits.
FINAL APPLICANT ACKNOWLEDGMENT
MY SUCCESSFUL ELECTRONIC SUBMISSION OF THIS APPLICATION SHALL SERVE AS MY CONFIRMATION AND ACKNOWLEDGMENT THAT I HAVE READ, UNDERSTOOD, AND AGREED TO THE ABOVE DECLARATIONS, AUTHORIZATIONS, MEDICAL DISCLOSURE REQUIREMENTS, SELECTED PAYMENT TERMS, SEMI-ANNUAL PAYMENT OBLIGATIONS WHERE APPLICABLE, MODAL SURCHARGE, NON-PAYMENT AND TERMINATION PROVISIONS, NON-CANCELLATION PROVISION, AND ACTIVATION RULES WITHOUT REQUIRING A SEPARATE HANDWRITTEN OR PHYSICAL SIGNATURE.
IF I SELECT THE SEMI-ANNUAL PAYMENT OPTION, I EXPRESSLY ACKNOWLEDGE THAT A 10% MODAL SURCHARGE APPLIES TO MY APPLICABLE ANNUAL PREMIUM. EACH SEMI-ANNUAL INSTALLMENT IS EQUIVALENT TO 55% OF THE APPLICABLE ANNUAL PREMIUM, SUBJECT TO ROUNDING WHERE APPLICABLE, AND THE TWO INSTALLMENTS COMBINED ARE EQUIVALENT TO 110% OF THE APPLICABLE ANNUAL PREMIUM.
I FURTHER ACKNOWLEDGE THAT PAYMENT OF THE FIRST SEMI-ANNUAL PREMIUM DOES NOT CONSTITUTE FULL PAYMENT FOR THE ENTIRE PLAN PERIOD. I AM RESPONSIBLE FOR SETTLING THE SUCCEEDING SEMI-ANNUAL PREMIUM ON OR BEFORE ITS APPLICABLE DUE DATE.
FAILURE TO SETTLE THE REQUIRED SUCCEEDING PREMIUM WITHIN THE APPLICABLE PAYMENT PERIOD MAY RESULT IN TERMINATION OF MY AYOS HEALTH CARD PLAN IN ACCORDANCE WITH THE APPLICABLE TERMS & CONDITIONS. FOLLOWING THE EFFECTIVE TERMINATION OF COVERAGE DUE TO NON-PAYMENT, IOSS INSURANCE AGENCY INC. / AYOS HEALTH CARD SHALL NOT BE LIABLE FOR CLAIMS, BENEFITS, MEDICAL EXPENSES, OR HEALTHCARE COSTS INCURRED AFTER THE EFFECTIVE TERMINATION DATE, SUBJECT TO APPLICABLE LAW AND THE AYOS HEALTH CARD TERMS & CONDITIONS.
I FURTHER ACKNOWLEDGE THAT ONCE MY APPLICATION IS SUCCESSFULLY SUBMITTED TOGETHER WITH THE REQUIRED PROOF OF PAYMENT AND PROCESSING HAS COMMENCED, MY APPLICATION IS CONSIDERED FINAL AND ENDORSED FOR PAYMENT VERIFICATION, ENROLLMENT, UNDERWRITING VALIDATION, AND ACTIVATION PROCESSING. REQUESTS FOR VOLUNTARY CANCELLATION, WITHDRAWAL, REVERSAL, OR REFUND DUE SOLELY TO A CHANGE OF MIND WILL NO LONGER BE ACCEPTED, SUBJECT TO APPLICABLE LAWS, REGULATIONS, CONTRACTUAL PROVISIONS, AND THE AYOS HEALTH CARD TERMS & CONDITIONS.
BY CLICKING “SUBMIT APPLICATION,” I VOLUNTARILY PROVIDE MY ELECTRONIC CONSENT AND AUTHORIZE THE PROCESSING OF MY AYOS HEALTH CARD 2.0 APPLICATION IN ACCORDANCE WITH THE TERMS STATED ABOVE.
