Formulario Seguro Sanitas Oficina Sanitas nro 19069

Health Insurance Application Form

The collection of this data will be used so that we can electronically send you the insurance application for you to sign. In no case does this data collection process signify the contracting of the insurance.

Discharge date: of

Leaving date: of

Data of the insured

Gender: FemaleMale

Payment method:

Health questionnaire

1 Do You have or have had an illness or accident within 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

If you checked "YES" to any of the questions, detail the reason, dates, and current status:

Do you want to hire coverage in case of traffic accident, car, bicycle, scooter and occupational accident?

Price: 1,5€ monthly or 17,28€ by annual payment
YESNO

Attach a copy of your passport (maximum size 1Mb):

Attach letter of admission from the school (maximum size 1Mb):

I accept the privacy policy YESNO