Statement of Cover

Effective Date. The date coverage takes effect. It is the date Pioneer acknowledges receipt
of the completed FREE MediCash Dengue Insurance online registration.

Coverage Period. Two (2) months from the Effective Date or from Effective Date up to Claim.
Once claim is paid, coverage terminates.

Insured. This is the person named in the online registration.

Benefit. Once coverage takes effect, Pioneer shall provide the maximum benefit of P3,000
Medical Cash Assistance to the Insured upon diagnosis of Dengue provided all of the following
conditions are satisfied:

1. It is the first and only claim for Dengue during the coverage period.
2. The signs and symptoms of Dengue should have been observed fifteen (15) days after
the Effective Date. The first consultation with a licensed physician related to the Dengue
diagnosis should not have also occurred during the said fifteen (15) days.
3. Dengue diagnosis is confirmed and certified by the Insured’s attending licensed physician
substantiated by relevant diagnostic tests, validated by Pioneer’s Medical Director
and/or authorized Medical Consultant.

Waiting Period. As there are no medical tests required when applying, a 15-day waiting period
from Effective Date is in effect. This means that no signs nor symptoms of the disease should
have been observed and that the first doctor’s consultation should not have occurred during
the waiting period.

Claims. The claims benefit is payable:

a. to the Insured, or
b. through the Insured’s legal guardian if the Insured is a minor, or
c. in successive preference to the 1) legal spouse 2) child(ren), 3) parents, 4) brothers
and sisters; otherwise, 5) the Insured’s estate, in case of the Insured’s passing
at the time of claims payment.

Claims Assistance
Text Dengue Claim to
Call 02 750 5433 Email PLI_OpsClaims@pioneer.com.ph 0917 531 7213 and we will call you.

PIONEER INSURANCE & SURETY CORPORATION

Pioneer House Makati, 108 Paseo de Roxas, Legaspi Village,
Makati City 1229, Philippines
Tel: +63 2 750 5433 • Fax: +63 2 817 1461 • www.pioneer.com.ph

Important Notice: The Insurance Commission, with offices in Manila, Cebu and Davao, is the government office
in charge of the enforcement of all laws related to insurance and has supervision over insurance providers
and intermediaries. It is ready at all times to assist the general public in matters pertaining to insurance.
For any inquiries or complaints, please contact the Public Assistance and Mediation Division (PAMD)
of the Insurance Commission at 1071 United Nations Avenue Manila with the telephone numbers +362 523 8461
to 70 and with email address pubassist@insurance.gov.ph. The official website of the Insurance Commission
is www.insurance.gov.ph.
 Does the Insured show signs and feel symptoms of Dengue? (Continuation of Medical Report)

2. Are you related to the patient? ( ) Yes ( ) No. If yes, how?

40oC

3. Please write out the History of Present Illness and your Physical Examination
Findings:

High Fever Rashes Headaches Body Pain

Follow these steps:

1. Consult a licensed physician and take the necessary diagnostic tests.
4. What were the laboratory tests or ancillary procedures done?
2. Ask the licensed physician to accomplish and sign the CLAIMS MEDICAL REPORT
What are the results? Please attach a copy of the results to this Medical Report.
(CMR) below.
3. If the licensed physician confirms the diagnosis as Dengue with the signed CMR,
submit it with the diagnostic test results to Pioneer by:
a. Scanning and sending via email to PLI_OpsClaims@pioneer.com.ph
b. Taking a picture and sending via Viber to 0917 531 7213
c. Delivering the hard copies to any Pioneer branch
5. Has the patient previously suffered from the condition specified under
the stated definition of Dengue? ( ) Yes ( ) No. If “Yes”, please state dates
CLAIMS MEDICAL REPORT (DENGUE) of consultation and resulting diagnosis.

To be filled out by the attending physician

In order for the claim to be valid, the following definitions must be fulfilled:

Dengue. An acute mosquito-borne viral illness of sudden onset that belongs 6. In your opinion, does the condition suffered by the patient fulfill the definition
to the genus Flaviviridae. This infectious tropical disease is characterized by high of Dengue? ( ) Yes ( ) No.
fever, rash, headache, swollen lymph nodes and severe muscle and joint pains.
Diagnosis must be a confirmed Dengue Fever (DF), Dengue Hemorrhagic Fever
(DHF), or Dengue Shock Syndrome (DSS). This should be confirmed by diagnostic
tests (Elisa IgM or Polymerase chain reaction).

Physician. A person legally licensed to practice medicine and/or perform surgery

in the Philippines and must not be the Insured himself nor any member
of his immediate family: parents, spouse, children, and siblings. DECLARATION

Name of Patient: I hereby certify that the above statements and facts which answer the preceding
questions are true and that I have not withheld any material information
Address: in connection with the above condition.

Diagnosis:
Date Physician’s Signature over Printed Name

1. Are you the patient’s usual medical attendant? ( ) Yes ( ) No.

Please state how long you have known the patient and provide the dates
of the first and last consultation:
License Number:

Contact No.: