"*" indica campos obligatorios

DATOS PERSONALES DEL TITULAR DE LA PÓLIZA

Nombre*

Nombre(s) Apellido(s) legal(es) completo(s)

NIF*

DNI, NIE o pasaporte

DATOS DE LA PERSONA A ASEGURAR

Nombre*

Nombre(s) Apellido(s) legal(es) completo(s)

NIF*

DNI, NIE o pasaporte

Adjunte el pasaporte o el NIE*

Tipos de archivos aceptados: jpg, jpeg, png, pdf, máx. tamaño del archivo: 5 MB.

Por favor, adjunte un escaneo o una foto de buena calidad del documento

Fecha de nacimiento*

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Edad nr*

Género*

Peso en kilogramos*

Altura en centímetros*

Relación con el solicitante*

Información de contacto

Teléfono*

Correo electrónico*

Dirección*

Dirección Ciudad Estado / Provincia / Región ZIP / Código Postal País

DATOS DEL REPRESENTANTE LEGAL

Nombre

Nombre(s) Apellido(s) legal(es) completo(s)

NIF

DNI, NIE o pasaporte

Póliza Fecha de entrada en vigor*

Por favor, seleccione el primer día del mes como fecha de inicio de su póliza. Las pólizas únicamente pueden comenzar el primer día de cada mes.

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INFORMACIÓN SANITARIA

1. ¿Sufre o ha sufrido alguna enfermedad en los últimos cinco años?*

SÍ

Especifique cuál, fecha, tratamiento y evolución*

¿Las enfermedades que ha padecido hasta ahora le han dejado alguna lesión o secuela?

SÍ

Especifique*

2. ¿Ha sido operado o ingresado en el hospital en algún momento?*

SÍ

Especifique la fecha y el motivo*

3. ¿En qué fecha y por qué motivo visitó al médico la última vez?*

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Razón*

Especifique la especialidad y la próxima fecha de visita*

4. ¿Ha padecido o padece algún defecto físico, deformidad, discapacidad o lesión congénita?*

SÍ

Especifique cuál, fecha, tratamiento y evolución*

5. ¿Ha sufrido algún traumatismo o accidente?*

SÍ

Especifique fecha, tratamiento y secuelas*

6. ¿Está actualmente bajo control médico o sigue algún tipo de tratamiento?*

SÍ

Especifique cuál*

a) ¿Sabe si necesitará algún estudio o tratamiento en el próximo año?*

SÍ

Especifique cuál*

b) ¿Necesitará ser hospitalizado en ese periodo de tiempo?*

SÍ

Indique el motivo*

7. ¿Es o ha sido fumador?*

SÍ

Especifique la cantidad por día*

¿Consume o ha consumido bebidas alcohólicas con regularidad?*

SÍ

Especifique la cantidad diaria y el tipo de bebidas*

¿Consume o ha consumido estupefacientes?*

SÍ

Especifique el tipo de productos*

Number of Beneficiaries

Por favor, escribe un número entre 1 y 7.

este Beneficiario nr

Benific. diferencia

si "0" enviar supp notif+ crear adhesión + enviar a pago

PERSON 2 DETAILS

Name*

Full legal first and middle names Full legal last name(s)

Tax ID No.*

DNI, NIE, or Passport

Please attach the passport or NIE*

Tipos de archivos aceptados: jpg, jpeg, png, pdf, máx. tamaño del archivo: 5 MB.

Please attach a scan or good quality photo of the document

Date of birth*

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Age nr*

Height in centimeters*

Weight in kilograms*

Gender*

Relationship with the applicant*

HEALTH-RELATED INFORMATION

1. Do you suffer or have you suffered any illness in the last five years?*

YES

Please specify which, date, treatment and evolution*

Have the illnesses you have suffered until now left any lesions or sequelae?

YES

Please specify*

2. Have you been operated on or admitted into hospital at any time?*

YES

Please specify date and reason*

3. At what date and for what reason did you visit the doctor the last time?*

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Reason*

Please specify speciality and next date for visit*

4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?*

YES

Please specify which, date, treatment and evolution*

5. Have you suffered any o traumatism or accident?*

YES

Please specify date, treatment and sequelae*

6. Are you currently under medical control or following any kind of treatment?*

YES

Please specify which*

a) Do you know whether you will need any study or treatment within the next year?*

YES

Please specify which*

b) Will you need to be admitted into hospital within that time period?*

YES

Please state the reason*

7. Are you or have you been a smoker?*

YES

Please specify amount per day*

Do you consume or have you consumed alcoholic drinks regularly?*

YES

Please specify amount per day and type of drinks*

Do you consume or have you consumed narcotics?*

YES

Please specify the type of products*

PERSON 3 DETAILS

Name*

Full legal first and middle names Full legal last name(s)

Tax ID No.*

DNI, NIE, or Passport

Please attach the passport or NIE*

Tipos de archivos aceptados: jpg, jpeg, png, pdf, máx. tamaño del archivo: 5 MB.

Please attach a scan or good quality photo of the document

Date of birth*

DD barra MM barra AAAA

Age nr*

Height in centimeters*

Weight in kilograms*

Gender*

Relationship with the applicant*

HEALTH-RELATED INFORMATION

1. Do you suffer or have you suffered any illness in the last five years?*

YES

Please specify which, date, treatment and evolution*

Have the illnesses you have suffered until now left any lesions or sequelae?

YES

Please specify*

2. Have you been operated on or admitted into hospital at any time?*

YES

Please specify date and reason*

3. At what date and for what reason did you visit the doctor the last time?*

DD barra MM barra AAAA

Reason*

Please specify speciality and next date for visit*

4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?*

YES

Please specify which, date, treatment and evolution*

5. Have you suffered any o traumatism or accident?*

YES

Please specify date, treatment and sequelae*

6. Are you currently under medical control or following any kind of treatment?*

YES

Please specify which*

a) Do you know whether you will need any study or treatment within the next year?*

YES

Please specify which*

b) Will you need to be admitted into hospital within that time period?*

YES

Please state the reason*

7. Are you or have you been a smoker?*

YES

Please specify amount per day*

Do you consume or have you consumed alcoholic drinks regularly?*

YES

Please specify amount per day and type of drinks*

Do you consume or have you consumed narcotics?*

YES

Please specify the type of products*

PERSON 4 DETAILS

Name*

Full legal first and middle names Full legal last name(s)

Tax ID No.*

DNI, NIE, or Passport

Please attach the passport or NIE*

Tipos de archivos aceptados: jpg, jpeg, png, pdf, máx. tamaño del archivo: 5 MB.

Please attach a scan or good quality photo of the document

Date of birth*

DD barra MM barra AAAA

Age nr*

Height in centimeters*

Weight in kilograms*

Gender*

Relationship with the applicant*

HEALTH-RELATED INFORMATION

1. Do you suffer or have you suffered any illness in the last five years?*

YES

Please specify which, date, treatment and evolution*

Have the illnesses you have suffered until now left any lesions or sequelae?

YES

Please specify*

2. Have you been operated on or admitted into hospital at any time?*

YES

Please specify date and reason*

3. At what date and for what reason did you visit the doctor the last time?*

DD barra MM barra AAAA

Reason*

Please specify speciality and next date for visit*

4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?*

YES

Please specify which, date, treatment and evolution*

5. Have you suffered any o traumatism or accident?*

YES

Please specify date, treatment and sequelae*

6. Are you currently under medical control or following any kind of treatment?*

YES

Please specify which*

a) Do you know whether you will need any study or treatment within the next year?*

YES

Please specify which*

b) Will you need to be admitted into hospital within that time period?*

YES

Please state the reason*

7. Are you or have you been a smoker?*

YES

Please specify amount per day*

Do you consume or have you consumed alcoholic drinks regularly?*

YES

Please specify amount per day and type of drinks*

Do you consume or have you consumed narcotics?*

YES

Please specify the type of products*

PERSON 5 DETAILS

Name*

Full legal first and middle names Full legal last name(s)

Tax ID No.*

DNI, NIE, or Passport

Please attach the passport or NIE*

Tipos de archivos aceptados: jpg, jpeg, png, pdf, máx. tamaño del archivo: 5 MB.

Please attach a scan or good quality photo of the document

Date of birth*

DD barra MM barra AAAA

Age nr*

Height in centimeters*

Weight in kilograms*

Gender*

Relationship with the applicant*

HEALTH-RELATED INFORMATION

1. Do you suffer or have you suffered any illness in the last five years?*

YES

Please specify which, date, treatment and evolution*

Have the illnesses you have suffered until now left any lesions or sequelae?

YES

Please specify*

2. Have you been operated on or admitted into hospital at any time?*

YES

Please specify date and reason*

3. At what date and for what reason did you visit the doctor the last time?*

DD barra MM barra AAAA

Reason*

Please specify speciality and next date for visit*

4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?*

YES

Please specify which, date, treatment and evolution*

5. Have you suffered any o traumatism or accident?*

YES

Please specify date, treatment and sequelae*

6. Are you currently under medical control or following any kind of treatment?*

YES

Please specify which*

a) Do you know whether you will need any study or treatment within the next year?*

YES

Please specify which*

b) Will you need to be admitted into hospital within that time period?*

YES

Please state the reason*

7. Are you or have you been a smoker?*

YES

Please specify amount per day*

Do you consume or have you consumed alcoholic drinks regularly?*

YES

Please specify amount per day and type of drinks*

Do you consume or have you consumed narcotics?*

YES

Please specify the type of products*

PERSON 6 DETAILS

Name*

Full legal first and middle names Full legal last name(s)

Tax ID No.*

DNI, NIE, or Passport

Please attach the passport or NIE*

Tipos de archivos aceptados: jpg, jpeg, png, pdf, máx. tamaño del archivo: 5 MB.

Please attach a scan or good quality photo of the document

Date of birth*

DD barra MM barra AAAA

Age nr*

Height in centimeters*

Weight in kilograms*

Gender*

Relationship with the applicant*

HEALTH-RELATED INFORMATION

1. Do you suffer or have you suffered any illness in the last five years?*

YES

Please specify which, date, treatment and evolution*

Have the illnesses you have suffered until now left any lesions or sequelae?

YES

Please specify*

2. Have you been operated on or admitted into hospital at any time?*

YES

Please specify date and reason*

3. At what date and for what reason did you visit the doctor the last time?*

DD barra MM barra AAAA

Reason*

Please specify speciality and next date for visit*

4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?*

YES

Please specify which, date, treatment and evolution*

5. Have you suffered any o traumatism or accident?*

YES

Please specify date, treatment and sequelae*

6. Are you currently under medical control or following any kind of treatment?*

YES

Please specify which*

a) Do you know whether you will need any study or treatment within the next year?*

YES

Please specify which*

b) Will you need to be admitted into hospital within that time period?*

YES

Please state the reason*

7. Are you or have you been a smoker?*

YES

Please specify amount per day*

Do you consume or have you consumed alcoholic drinks regularly?*

YES

Please specify amount per day and type of drinks*

Do you consume or have you consumed narcotics?*

YES

Please specify the type of products*

PERSON 7 DETAILS

Name*

Full legal first and middle names Full legal last name(s)

Tax ID No.*

DNI, NIE, or Passport

Please attach the passport or NIE*

Tipos de archivos aceptados: jpg, jpeg, png, pdf, máx. tamaño del archivo: 5 MB.

Please attach a scan or good quality photo of the document

Date of birth*

DD barra MM barra AAAA

Age nr*

Height in centimeters*

Weight in kilograms*

Gender*

Relationship with the applicant*

HEALTH-RELATED INFORMATION

1. Do you suffer or have you suffered any illness in the last five years?*

YES

Please specify which, date, treatment and evolution*

Have the illnesses you have suffered until now left any lesions or sequelae?

YES

Please specify*

2. Have you been operated on or admitted into hospital at any time?*

YES

Please specify date and reason*

3. At what date and for what reason did you visit the doctor the last time?*

DD barra MM barra AAAA

Reason*

Please specify speciality and next date for visit*

4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?*

YES

Please specify which, date, treatment and evolution*

5. Have you suffered any o traumatism or accident?*

YES

Please specify date, treatment and sequelae*

6. Are you currently under medical control or following any kind of treatment?*

YES

Please specify which*

a) Do you know whether you will need any study or treatment within the next year?*

YES

Please specify which*

b) Will you need to be admitted into hospital within that time period?*

YES

Please state the reason*

7. Are you or have you been a smoker?*

YES

Please specify amount per day*

Do you consume or have you consumed alcoholic drinks regularly?*

YES

Please specify amount per day and type of drinks*

Do you consume or have you consumed narcotics?*

YES

Please specify the type of products*

Importe*

Periodo de cobertura en meses*

Precio mensual*

Precio total para todos los solicitantes

El abajo firmante manifiesta, bajo su responsabilidad, que sus respuestas a las preguntas formuladas son veraces y completas, autorizando a SegurCaixa Adeslas a realizar cuantas comprobaciones estime convenientes sobre el origen y evolución de las enfermedades o dolencias que puedan, dado el caso, requerir la asistencia prevista en esta Póliza. El abajo firmante autoriza a la Compañía, en caso de enfermedad, a ponerse en contacto con los médicos intervinientes.

SegurCaixa Adeslas podrá resolver sobre la Póliza en el plazo de un mes desde que tenga conocimiento de las reservas o inexactitudes del declarante en la cumplimentación del cuestionario, si bien este derecho no podrá fundarse en el desconocimiento por parte de la Aseguradora de datos sobre el estado de salud del Tomador no incluidos en las preguntas anteriores.

Si existiera dolo o culpa grave en la cumplimentación de este cuestionario, SegurCaixa Adeslas quedará en todo caso y en adelante liberada de las obligaciones que para ella establece la póliza de seguro (Art. 10 Ley de Contrato de Seguro)

Protección de datos*

He leído y aceptado la política de protección de datos

Renovaciones y devoluciones*

Entiendo que, como exige la legislación española, el contrato de seguro se renovará automáticamente cada año, a menos que yo comunique lo contrario por escrito al menos 30 días antes de la fecha de renovación. También reconozco que los reembolsos sólo están disponibles en caso de denegación del visado, previa presentación de una carta legal de denegación, y se basarán en los meses de cobertura.

Firma*