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This field is for validation purposes and should be left unchanged.

Policyholder details

Policyholder Name*

First name(s) Surname(s)

Date of Birth*

DD slash MM slash YYYY

Nationality*

Country

Sex*

Male

Female

ID Document*

Passport

NIE

DNI

ID Number*

Email*

Phone*

Policyholder's Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Insured persons

How many people will be insured under this policy?

Number of Insured*

Please enter a number from 1 to 6.

Insured 1 — Details

If the Policyholder is also an insured person, list them as Insured 1.

Insured Name*

First name(s) Surname(s)

Sex*

Male

Female

Date of Birth*

DD slash MM slash YYYY

Nationality*

Country

Profession*

ID Document*

Passport

NIE

DNI

ID Number*

Please attach your passport or NIE*

Please attach a scan or good quality photo of the document

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Height (cm)*

Please enter a number greater than or equal to 40.

Weight (kg)*

Please enter a number greater than or equal to 1.

Have you previously been insured by Unión Madrileña?*

Yes

Previous policy number*

Do you come from another insurance company?*

Yes

Which company?*

Insured 1 — Confidential Medical Information

Have you been hospitalised, admitted to a clinic, or had surgery?*

Yes

If yes, please detail (including dates)*

Do you have any diagnostic test, medical treatment, or surgery scheduled?*

Yes

If yes, please detail*

Are you currently receiving medical treatment or under medical supervision?*

Yes

If yes, please detail*

If female, are you currently pregnant?*

Yes

How many weeks?*

Please enter a number from 0 to 42.

Declaration of other illnesses
Have you suffered, or do you currently suffer, any of the following? Tick all that apply.

Cancer / oncological processes

Congenital diseases

Demyelinating diseases

Parkinson's disease

Epilepsy

Intramedullary / intracranial pathology

Paraplegia / hemiplegia / tetraplegia

Arteriosclerosis

Aortic aneurysm

Ischemic / valvular / cardiomyopathic heart disease

Malignant hypertension

Pulmonary fibrosis

Chronic respiratory failure

Cerebrovascular disease

Chronic kidney failure

Chronic hepatopathy or pancreatitis

Endocrine-metabolic pathology

Ulcerative colitis / Crohn's disease

Endometriosis

Rheumatoid or psoriatic arthritis

Muscular dystrophy

Systemic lupus

Dermatomyositis

Ankylosing spondylitis

Severe haematological disorders

Osteoarticular surgery with prosthesis or implants

Degenerative / accidental spine, hip, knee, shoulder or foot pathology

Psychiatric disorders

Eating disorders

Transplants

Allergies / Intolerances

Insured 1 — Additional Confidential Medical Questionnaire

Complete this questionnaire because you have flagged at least one health issue above. Up to 4 separate problems. For paired organs or limbs, indicate the side.

Problem 1

Problem 1: Current or Past?*

Current

Past

Start date*

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem*

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 2

Problem 2: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 3

Problem 3: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 4

Problem 4: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

7th — Refractive eye defect

Specify (myopia, hyperopia, astigmatism, etc.)

Dioptres left eye

Dioptres right eye

Newborn

Week of gestation at birth

Birth weight (kg)

Type of assistance received or required

Incubator

Intermediate care

ICU

Paediatric consultations

Paediatric specialty

Specify congenital condition

Insured 2 — Details

Insured Name*

First name(s) Surname(s)

Relationship with the policyholder*

Sex*

Male

Female

Date of Birth*

DD slash MM slash YYYY

Nationality*

Country

Profession*

ID Document*

Passport

NIE

DNI

ID Number*

Please attach your passport or NIE*

Please attach a scan or good quality photo of the document

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Height (cm)*

Please enter a number greater than or equal to 40.

Weight (kg)*

Please enter a number greater than or equal to 1.

Have you previously been insured by Unión Madrileña?*

Yes

Previous policy number*

Do you come from another insurance company?*

Yes

Which company?*

Insured 2 — Confidential Medical Information

Have you been hospitalised, admitted to a clinic, or had surgery?*

Yes

If yes, please detail (including dates)*

Do you have any diagnostic test, medical treatment, or surgery scheduled?*

Yes

If yes, please detail*

Are you currently receiving medical treatment or under medical supervision?*

Yes

If yes, please detail*

If female, are you currently pregnant?*

Yes

How many weeks?*

Please enter a number from 0 to 42.

Declaration of other illnesses
Have you suffered, or do you currently suffer, any of the following? Tick all that apply.

Cancer / oncological processes

Congenital diseases

Demyelinating diseases

Parkinson's disease

Epilepsy

Intramedullary / intracranial pathology

Paraplegia / hemiplegia / tetraplegia

Arteriosclerosis

Aortic aneurysm

Ischemic / valvular / cardiomyopathic heart disease

Malignant hypertension

Pulmonary fibrosis

Chronic respiratory failure

Cerebrovascular disease

Chronic kidney failure

Chronic hepatopathy or pancreatitis

Endocrine-metabolic pathology

Ulcerative colitis / Crohn's disease

Endometriosis

Rheumatoid or psoriatic arthritis

Muscular dystrophy

Systemic lupus

Dermatomyositis

Ankylosing spondylitis

Severe haematological disorders

Osteoarticular surgery with prosthesis or implants

Degenerative / accidental spine, hip, knee, shoulder or foot pathology

Psychiatric disorders

Eating disorders

Transplants

Allergies / Intolerances

Insured 2 — Additional Confidential Medical Questionnaire

Complete this questionnaire because you have flagged at least one health issue above. Up to 4 separate problems. For paired organs or limbs, indicate the side.

Problem 1

Problem 1: Current or Past?*

Current

Past

Start date*

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem*

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 2

Problem 2: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 3

Problem 3: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 4

Problem 4: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

7th — Refractive eye defect

Specify (myopia, hyperopia, astigmatism, etc.)

Dioptres left eye

Dioptres right eye

Newborn

Week of gestation at birth

Birth weight (kg)

Type of assistance received or required

Incubator

Intermediate care

ICU

Paediatric consultations

Paediatric specialty

Specify congenital condition

Insured 3 — Details

Insured Name*

First name(s) Surname(s)

Relationship with the policyholder*

Sex*

Male

Female

Date of Birth*

DD slash MM slash YYYY

Nationality*

Country

Profession*

ID Document*

Passport

NIE

DNI

ID Number*

Please attach your passport or NIE*

Please attach a scan or good quality photo of the document

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Height (cm)*

Please enter a number greater than or equal to 40.

Weight (kg)*

Please enter a number greater than or equal to 1.

Have you previously been insured by Unión Madrileña?*

Yes

Previous policy number*

Do you come from another insurance company?*

Yes

Which company?*

Insured 3 — Confidential Medical Information

Have you been hospitalised, admitted to a clinic, or had surgery?*

Yes

If yes, please detail (including dates)*

Do you have any diagnostic test, medical treatment, or surgery scheduled?*

Yes

If yes, please detail*

Are you currently receiving medical treatment or under medical supervision?*

Yes

If yes, please detail*

If female, are you currently pregnant?*

Yes

How many weeks?*

Please enter a number from 0 to 42.

Declaration of other illnesses
Have you suffered, or do you currently suffer, any of the following? Tick all that apply.

Cancer / oncological processes

Congenital diseases

Demyelinating diseases

Parkinson's disease

Epilepsy

Intramedullary / intracranial pathology

Paraplegia / hemiplegia / tetraplegia

Arteriosclerosis

Aortic aneurysm

Ischemic / valvular / cardiomyopathic heart disease

Malignant hypertension

Pulmonary fibrosis

Chronic respiratory failure

Cerebrovascular disease

Chronic kidney failure

Chronic hepatopathy or pancreatitis

Endocrine-metabolic pathology

Ulcerative colitis / Crohn's disease

Endometriosis

Rheumatoid or psoriatic arthritis

Muscular dystrophy

Systemic lupus

Dermatomyositis

Ankylosing spondylitis

Severe haematological disorders

Osteoarticular surgery with prosthesis or implants

Degenerative / accidental spine, hip, knee, shoulder or foot pathology

Psychiatric disorders

Eating disorders

Transplants

Allergies / Intolerances

Insured 3 — Additional Confidential Medical Questionnaire

Complete this questionnaire because you have flagged at least one health issue above. Up to 4 separate problems. For paired organs or limbs, indicate the side.

Problem 1

Problem 1: Current or Past?*

Current

Past

Start date*

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem*

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 2

Problem 2: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 3

Problem 3: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 4

Problem 4: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

7th — Refractive eye defect

Specify (myopia, hyperopia, astigmatism, etc.)

Dioptres left eye

Dioptres right eye

Newborn

Week of gestation at birth

Birth weight (kg)

Type of assistance received or required

Incubator

Intermediate care

ICU

Paediatric consultations

Paediatric specialty

Specify congenital condition

Insured 4 — Details

Insured Name*

First name(s) Surname(s)

Relationship with the policyholder*

Sex*

Male

Female

Date of Birth*

DD slash MM slash YYYY

Nationality*

Country

Profession*

ID Document*

Passport

NIE

DNI

ID Number*

Please attach your passport or NIE*

Please attach a scan or good quality photo of the document

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Height (cm)*

Please enter a number greater than or equal to 40.

Weight (kg)*

Please enter a number greater than or equal to 1.

Have you previously been insured by Unión Madrileña?*

Yes

Previous policy number*

Do you come from another insurance company?*

Yes

Which company?*

Insured 4 — Confidential Medical Information

Have you been hospitalised, admitted to a clinic, or had surgery?*

Yes

If yes, please detail (including dates)*

Do you have any diagnostic test, medical treatment, or surgery scheduled?*

Yes

If yes, please detail*

Are you currently receiving medical treatment or under medical supervision?*

Yes

If yes, please detail*

If female, are you currently pregnant?*

Yes

How many weeks?*

Please enter a number from 0 to 42.

Declaration of other illnesses
Have you suffered, or do you currently suffer, any of the following? Tick all that apply.

Cancer / oncological processes

Congenital diseases

Demyelinating diseases

Parkinson's disease

Epilepsy

Intramedullary / intracranial pathology

Paraplegia / hemiplegia / tetraplegia

Arteriosclerosis

Aortic aneurysm

Ischemic / valvular / cardiomyopathic heart disease

Malignant hypertension

Pulmonary fibrosis

Chronic respiratory failure

Cerebrovascular disease

Chronic kidney failure

Chronic hepatopathy or pancreatitis

Endocrine-metabolic pathology

Ulcerative colitis / Crohn's disease

Endometriosis

Rheumatoid or psoriatic arthritis

Muscular dystrophy

Systemic lupus

Dermatomyositis

Ankylosing spondylitis

Severe haematological disorders

Osteoarticular surgery with prosthesis or implants

Degenerative / accidental spine, hip, knee, shoulder or foot pathology

Psychiatric disorders

Eating disorders

Transplants

Allergies / Intolerances

Insured 4 — Additional Confidential Medical Questionnaire

Complete this questionnaire because you have flagged at least one health issue above. Up to 4 separate problems. For paired organs or limbs, indicate the side.

Problem 1

Problem 1: Current or Past?*

Current

Past

Start date*

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem*

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 2

Problem 2: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 3

Problem 3: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 4

Problem 4: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

7th — Refractive eye defect

Specify (myopia, hyperopia, astigmatism, etc.)

Dioptres left eye

Dioptres right eye

Newborn

Week of gestation at birth

Birth weight (kg)

Type of assistance received or required

Incubator

Intermediate care

ICU

Paediatric consultations

Paediatric specialty

Specify congenital condition

Insured 5 — Details

Insured Name*

First name(s) Surname(s)

Relationship with the policyholder*

Sex*

Male

Female

Date of Birth*

DD slash MM slash YYYY

Nationality*

Country

Profession*

ID Document*

Passport

NIE

DNI

ID Number*

Please attach your passport or NIE*

Please attach a scan or good quality photo of the document

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Height (cm)*

Please enter a number greater than or equal to 40.

Weight (kg)*

Please enter a number greater than or equal to 1.

Have you previously been insured by Unión Madrileña?*

Yes

Previous policy number*

Do you come from another insurance company?*

Yes

Which company?*

Insured 5 — Confidential Medical Information

Have you been hospitalised, admitted to a clinic, or had surgery?*

Yes

If yes, please detail (including dates)*

Do you have any diagnostic test, medical treatment, or surgery scheduled?*

Yes

If yes, please detail*

Are you currently receiving medical treatment or under medical supervision?*

Yes

If yes, please detail*

If female, are you currently pregnant?*

Yes

How many weeks?*

Please enter a number from 0 to 42.

Declaration of other illnesses
Have you suffered, or do you currently suffer, any of the following? Tick all that apply.

Cancer / oncological processes

Congenital diseases

Demyelinating diseases

Parkinson's disease

Epilepsy

Intramedullary / intracranial pathology

Paraplegia / hemiplegia / tetraplegia

Arteriosclerosis

Aortic aneurysm

Ischemic / valvular / cardiomyopathic heart disease

Malignant hypertension

Pulmonary fibrosis

Chronic respiratory failure

Cerebrovascular disease

Chronic kidney failure

Chronic hepatopathy or pancreatitis

Endocrine-metabolic pathology

Ulcerative colitis / Crohn's disease

Endometriosis

Rheumatoid or psoriatic arthritis

Muscular dystrophy

Systemic lupus

Dermatomyositis

Ankylosing spondylitis

Severe haematological disorders

Osteoarticular surgery with prosthesis or implants

Degenerative / accidental spine, hip, knee, shoulder or foot pathology

Psychiatric disorders

Eating disorders

Transplants

Allergies / Intolerances

Insured 5 — Additional Confidential Medical Questionnaire

Complete this questionnaire because you have flagged at least one health issue above. Up to 4 separate problems. For paired organs or limbs, indicate the side.

Problem 1

Problem 1: Current or Past?*

Current

Past

Start date*

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem*

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 2

Problem 2: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 3

Problem 3: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 4

Problem 4: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

7th — Refractive eye defect

Specify (myopia, hyperopia, astigmatism, etc.)

Dioptres left eye

Dioptres right eye

Newborn

Week of gestation at birth

Birth weight (kg)

Type of assistance received or required

Incubator

Intermediate care

ICU

Paediatric consultations

Paediatric specialty

Specify congenital condition

Insured 6 — Details

Insured Name*

First name(s) Surname(s)

Relationship with the policyholder*

Sex*

Male

Female

Date of Birth*

DD slash MM slash YYYY

Nationality*

Country

Profession*

ID Document*

Passport

NIE

DNI

ID Number*

Please attach your passport or NIE*

Please attach a scan or good quality photo of the document

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Height (cm)*

Please enter a number greater than or equal to 40.

Weight (kg)*

Please enter a number greater than or equal to 1.

Have you previously been insured by Unión Madrileña?*

Yes

Previous policy number*

Do you come from another insurance company?*

Yes

Which company?*

Insured 6 — Confidential Medical Information

Have you been hospitalised, admitted to a clinic, or had surgery?*

Yes

If yes, please detail (including dates)*

Do you have any diagnostic test, medical treatment, or surgery scheduled?*

Yes

If yes, please detail*

Are you currently receiving medical treatment or under medical supervision?*

Yes

If yes, please detail*

If female, are you currently pregnant?*

Yes

How many weeks?*

Please enter a number from 0 to 42.

Declaration of other illnesses
Have you suffered, or do you currently suffer, any of the following? Tick all that apply.

Cancer / oncological processes

Congenital diseases

Demyelinating diseases

Parkinson's disease

Epilepsy

Intramedullary / intracranial pathology

Paraplegia / hemiplegia / tetraplegia

Arteriosclerosis

Aortic aneurysm

Ischemic / valvular / cardiomyopathic heart disease

Malignant hypertension

Pulmonary fibrosis

Chronic respiratory failure

Cerebrovascular disease

Chronic kidney failure

Chronic hepatopathy or pancreatitis

Endocrine-metabolic pathology

Ulcerative colitis / Crohn's disease

Endometriosis

Rheumatoid or psoriatic arthritis

Muscular dystrophy

Systemic lupus

Dermatomyositis

Ankylosing spondylitis

Severe haematological disorders

Osteoarticular surgery with prosthesis or implants

Degenerative / accidental spine, hip, knee, shoulder or foot pathology

Psychiatric disorders

Eating disorders

Transplants

Allergies / Intolerances

Insured 6 — Additional Confidential Medical Questionnaire

Complete this questionnaire because you have flagged at least one health issue above. Up to 4 separate problems. For paired organs or limbs, indicate the side.

Problem 1

Problem 1: Current or Past?*

Current

Past

Start date*

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem*

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 2

Problem 2: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 3

Problem 3: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

Problem 4

Problem 4: Current or Past?

Current

Past

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Describe the problem

1st — Cause (e.g. illness, accident, congenital, pregnancy, etc.)

2nd — Exact location (e.g. left leg, right arm, ears, etc.)

3rd — Treatment (medical, surgical, etc.)

4th — Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)

5th — Future planned diagnostic tests or treatments

6th — Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)

7th — Refractive eye defect

Specify (myopia, hyperopia, astigmatism, etc.)

Dioptres left eye

Dioptres right eye

Newborn

Week of gestation at birth

Birth weight (kg)

Type of assistance received or required

Incubator

Intermediate care

ICU

Paediatric consultations

Paediatric specialty

Specify congenital condition

Monthly Health Insurance price

Optional supplements

Do you want to add any of the following supplements?

Supplements

Dental

4,5€ / month per applicant

Dental Insurance Price*

Monthly price*

Total price for all applicants

Date of effect of the policy*

Please select the 1st day of the month as the start date for your policy. Policies can only commence on the first day of any given month.

DD slash MM slash YYYY

Declaration and signature

I declare that I have answered truthfully everything stated in this application and acknowledge having received the information prior to signing the insurance. I consent to the processing of personal data.

STATEMENT OF ACKNOWLEDGMENT AND ACCEPTANCE OF THE TERMS OF USE OF THE MEDICAL NETWORK CONTRACTED BY THE COMPANY AND REIMBURSEMENT COMMITMENT (v1.2)

Between LA UNIÓN MADRILEÑA DE SEGUROS, S.A. (registered office: Calle Viriato, nº 2, 28010 Madrid; C.I.F. A-28081818; DGSFP register no. C0368) — the "Insurer" — and the Applicant (future Policyholder).

EXPLANATORY STATEMENTS

1. The Applicant, as a foreigner, is contracting Health Assistance Insurance with the Insurer in order to meet the legal residence requirements in Spain under Organic Law 4/2000 (Immigration Law) and Royal Decree 240/2007, regarding accreditation of health coverage equivalent to that of the National Health System.

2. The coverage operates under a Closed Network: medical services are provided exclusively through professionals and medical or hospital centres contracted by the Insurer. The Applicant acknowledges having been informed of the composition of this network and agrees with it and with the scope of the coverage provided.

3. The Applicant declares having been clearly and precisely informed about the composition of the agreed network, accepting it as an essential condition for the Insurer's risk assessment.

4. This agreement regulates the legal and economic consequences should the Applicant or any beneficiary voluntarily seek medical assistance at centres not included in the Insurer's medical directory.

CLAUSES

FIRST — Delimitation of risk and commitment to use the agreed network.
Healthcare is guaranteed only through the Insurer's medical facilities or affiliated hospitals. Any assistance received at centres outside the contracted network (public or private) is considered not covered — except in cases of vital emergency under Clause Four — and exempts the Insurer from any obligation of payment, advance or reimbursement.

SECOND — Obligation to inform beneficiaries.
The Applicant undertakes to forward the contents of this document to all beneficiaries and, as future Policyholder, will be personally liable to the Insurer for any expenses arising from the beneficiaries' failure to comply.

THIRD — Means of consulting the medical staff.
The Insurer provides the full network list through: the digital platform and mobile app (www.unionmadrilena.es, real-time updates); 24-hour telephone support (free number 900 799 148, 365 days a year); and PDF/physical format provided with the Special Conditions. The Applicant must consult these resources before receiving any benefit; ignorance of the network does not exempt the Applicant from assuming the costs of care obtained through the public system or a non-affiliated private entity.

FOURTH — Exception for imminent life-threatening emergency.
The obligation to use the agreed network does not apply in cases of imminent life emergency (an unforeseen clinical situation posing an immediate and irreversible risk to life or physical integrity, where distance or severity prevents transfer to a contracted facility). Coverage is limited to the care necessary until clinical stabilisation and possible transfer to the contracted network. The Insurer is not responsible for the quality, outcome or incidents of such care.

FIFTH — Assumption of costs and right of recovery.
Except in life-threatening emergencies, if the Applicant or beneficiaries voluntarily attend the public health network or external private centres and these bill the Insurer, the Applicant must reimburse the Insurer 100% of the full invoiced amount within a maximum of 15 calendar days from notification of the charge.

SIXTH — Duty of confidentiality.
The Applicant will maintain strict discretion regarding the existence of the policy with respect to third parties and manage healthcare requests on a strictly personal basis. Should policy details be disclosed to the public healthcare network — and any resulting claim be made against the Insurer — the Applicant assumes sole financial responsibility for the resulting invoices, which will be sent for reimbursement.

SEVENTH — Resolutory condition for non-compliance.
The validity of the insurance contract is subject to compliance with the reimbursement obligations herein. Refusal to pay the medical costs incurred, or the return of the corresponding bank receipts, entitles the Insurer to immediate termination of the contract for breach of essential conditions. As this insurance is a requirement for legal residency, the Insurer will notify the termination to the competent Immigration Authorities for the appropriate legal purposes and consequences.

EIGHTH — Specific acceptance of limitative clauses.
The Applicant declares having read and understood this document and expressly acknowledges that the clauses establishing (i) exclusion of coverage outside the medical network, (ii) the obligation to reimburse expenses billed by third parties, and (iii) the right to terminate the contract, constitute clauses limiting their rights, which are specifically and separately accepted by signing, as required by Article 3 of Law 50/1980 on Insurance Contracts.

I have read, understood and expressly accept the Terms of Use of the Contracted Medical Network and the Reimbursement Commitment set out below (v1.2). I specifically and separately accept the limitative clauses they contain, as required by Article 3 of Law 50/1980 on Insurance Contracts.

Data protection consent*

I have read and accepted the data protection policy

Renewals and Refunds*

I understand that, as required by Spanish law, the insurance contract will be automatically renewed annually unless I inform otherwise in writing at least 30 days prior to the renewal date. I also acknowledge that refunds are only available in case of visa denial, upon presentation of a legal denial letter, and will be based on the months of coverage.

Signature*

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Language

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