Solicitud de presupuesto de seguro de salud

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Name*

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Individual 2

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Are you sure that the Date of Birth is correct?

Individual 3

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Individual 4

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Individual 5

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Individual 6

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Individual 7

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Conditions

Please let us know if you suffer or have suffered from any of the following injuries or conditions, by ticking the boxes where appropriate.

Conditions

Please let us know if any of the applicants suffer or have suffered from any of the following injuries or conditions, by ticking the boxes where appropriate.

Cancer
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Diabetes
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Hepatitis
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Cardiac
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Metabolic
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Rheumatological
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Nervous system
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Haematological
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Kidney
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Infectious
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Transplants
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Pregnancy
Complications
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Other Ailments
Nothing to declare
Medical conditions selected
Will you need the proof of Insurance?*
Proof of coverage will be required if you apply for or renew your Spanish Visa. Also it can be required by other Spanish institutions.
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Spanish national ID*
Do all individuals to include in the coverage hold Spanish DNI or NIE number?
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Disabled 11/11/2022
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Which month you want your policy to start
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