Form 4 insured - Seguro Médico

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

Discharge date:

Data of the insured

Gender: FemaleMale

Attach passport copy (max size 1Mb):

Insured address: (address in Spain)

Payment data

Payment mode:

Frequency

Only available in case of payment by bank account.

Payment frequency:

Health questionnaire

1 Do you suffer or have you suffered from any illness or have you suffered an accident in the last five years that required medical treatment?
YESNO

2 Have you ever been or do you plan to be hospitalized and/or undergo surgery?
YESNO

3 Are you currently under medical treatment?
YESNO

4 Do you have any undiagnosed symptoms or pain that is ongoing or recurrent?
YESNO

Data of the insured 2

Gender: FemaleMale

Attach passport copy (max size 1Mb):

Health questionnaire

1 Do you suffer or have you suffered from any illness or have you suffered an accident in the last five years that required medical treatment?
YESNO

2 Have you ever been or do you plan to be hospitalized and/or undergo surgery?
YESNO

3 Are you currently under medical treatment?
YESNO

4 Do you have any undiagnosed symptoms or pain that is ongoing or recurrent?
YESNO

33%

Data of the insured 3

Gender: FemaleMale

Attach passport copy (max size 1Mb):

Health questionnaire

1 Do you suffer or have you suffered from any illness or have you suffered an accident in the last five years that required medical treatment?
YESNO

2 Have you ever been or do you plan to be hospitalized and/or undergo surgery?
YESNO

3 Are you currently under medical treatment?
YESNO

4 Do you have any undiagnosed symptoms or pain that is ongoing or recurrent?
YESNO

66%

Data of the insured 4

Gender: FemaleMale

Attach passport copy (max size 1Mb):

Health questionnaire

1 Do you suffer or have you suffered from any illness or have you suffered an accident in the last five years that required medical treatment?
YESNO

2 Have you ever been or do you plan to be hospitalized and/or undergo surgery?
YESNO

3 Are you currently under medical treatment?
YESNO

4 Do you have any undiagnosed symptoms or pain that is ongoing or recurrent?
YESNO

I accept the privacy policy YESNO

100%