Health Insurance Application Form – 4 Beneficiaries

Taking this information will help us to send you the insurance application electronically so that you can sign it. In no case this data collection process mean the contracting of insurance.

    • 1

      INSURED 1

    • 2

      INSURED 2

    • 3

      INSURED 3

    • 4

      INSURED 4

    1/4

    INSURED 1

    Data of the insured

    Insured address: (address in Spain)

    Payment data

    Frequency

    Only available in case of payment by bank account.

    Health questionnaire


    YESNO


    YESNO


    YESNO


    YESNO

    0%

    Data of the insured 2

    Health questionnaire


    YESNO


    YESNO


    YESNO


    YESNO

    33%

    Data of the insured 3

    Health questionnaire


    YESNO


    YESNO


    YESNO


    YESNO

    66%

    Data of the insured 4

    Health questionnaire


    YESNO


    YESNO


    YESNO


    YESNO

    100%