"*" indica campos obligatorios

Company

Este campo es un campo de validación y debe quedar sin cambios.

Policyholder details

Policyholder Name*

First name(s) Surname(s)

Date of Birth*

DD barra MM barra AAAA

Nationality*

País

Sex*

Male

Female

ID Document*

Passport

NIE

DNI

ID Number*

Email*

Phone*

Policyholder's Address*

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

Insured persons

How many people will be insured under this policy?

Number of Insured*

Por favor, escribe un número entre 1 y 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 barra MM barra AAAA

Nationality*

País

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

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

Height (cm)*

Por favor, escribe un número mayor o igual a 40.

Weight (kg)*

Por favor, escribe un número mayor o igual a 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?*

Por favor, escribe un número entre 0 y 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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

Nationality*

País

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

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

Height (cm)*

Por favor, escribe un número mayor o igual a 40.

Weight (kg)*

Por favor, escribe un número mayor o igual a 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?*

Por favor, escribe un número entre 0 y 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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

Nationality*

País

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

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

Height (cm)*

Por favor, escribe un número mayor o igual a 40.

Weight (kg)*

Por favor, escribe un número mayor o igual a 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?*

Por favor, escribe un número entre 0 y 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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

Nationality*

País

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

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

Height (cm)*

Por favor, escribe un número mayor o igual a 40.

Weight (kg)*

Por favor, escribe un número mayor o igual a 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?*

Por favor, escribe un número entre 0 y 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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

Nationality*

País

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

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

Height (cm)*

Por favor, escribe un número mayor o igual a 40.

Weight (kg)*

Por favor, escribe un número mayor o igual a 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?*

Por favor, escribe un número entre 0 y 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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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 barra MM barra AAAA

Nationality*

País

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

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

Height (cm)*

Por favor, escribe un número mayor o igual a 40.

Weight (kg)*

Por favor, escribe un número mayor o igual a 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?*

Por favor, escribe un número entre 0 y 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*

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End date

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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

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End date

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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

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End date

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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 barra MM barra AAAA

End date

DD barra MM barra AAAA

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.

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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.

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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Exclude workflow

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affwp_ref

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Language

Order nr