Health Insurance Contract

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Name*

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

Spell your name exactly as it's shown on your passport or ID card.

Identification Document*

Document number*

Please attach your passport or NIE*

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 4 MB.

Please attach a scan or good quality photo of the document

Address*

address city province zip country

Region where you will live in Spain*

Email*

Phone*

Date of Birth*

DD dash MM dash YYYY

Age 0

Height in Centimetres*

Weight in kilograms*

Marital status*

Sex*

Male

Female

Nationality*

Profession*

Number of Beneficiaries in Total*

Please enter a number from 1 to 7.

Date of effect of the policy*

DD dash MM dash YYYY

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.

IMPORTANT! The proof of insurance certificate from Asisa will be made available no earlier than 60 days prior to the policy's effective date.

IMPORTANT! The proof of insurance certificate from Sanitas will be made available no earlier than 90 days prior to the policy's effective date.

A fee of 150€ will be charged if certificate must be provided more than 60 days prior to the policy's effective date.

IMPORTANT! The proof of insurance certificate from DKV will be made available no earlier than 180 days prior to the policy's effective date.

A fee of 150€ will be charged if certificate must be provided more than 60 days prior to the policy's effective date.

Additional Beneficiary 1 Form

Date of Birth*

DD dash MM dash YYYY

Age 1

Name*

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

Spell the name exactly as it's shown on the passport or ID card.

ID*

ID Number*

Please attach ID*

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 4 MB.

Height in Centimetres*

Weight in kilograms*

Marital Status*

Sex*

Male

Female

Profession*

Additional Beneficiary 2 Form

Date of Birth*

DD dash MM dash YYYY

Age 2

Name*

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

Spell the name exactly as it's shown on the passport or ID card.

ID*

ID Number*

Please attach ID*

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 4 MB.

Height in Centimetres*

Weight in kilograms*

Marital Status*

Sex*

Male

Female

Profession*

Additional Beneficiary 3 Form

Date of Birth*

DD dash MM dash YYYY

Age 3

Name*

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

Spell the name exactly as it's shown on the passport or ID card.

ID*

ID Number*

Please attach ID*

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 4 MB.

Height in Centimetres*

Weight in kilograms*

Marital Status*

Sex*

Male

Female

Profession*

Additional Beneficiary 4 Form

Date of Birth*

DD dash MM dash YYYY

Age 4

Name*

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

Spell the name exactly as it's shown on the passport or ID card.

ID*

ID Number*

Please attach ID*

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 4 MB.

Height in Centimetres*

Weight in kilograms*

Marital Status*

Sex*

Male

Female

Profession*

Additional Beneficiary 5 Form

Date of Birth*

DD dash MM dash YYYY

Age 5

Name*

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

Spell the name exactly as it's shown on the passport or ID card.

ID*

ID Number*

Please attach ID*

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 4 MB.

Height in Centimetres*

Weight in kilograms*

Marital Status*

Sex*

Male

Female

Profession*

Additional Beneficiary 6 Form

Date of Birth*

DD dash MM dash YYYY

Age 6

Name*

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

Spell the name exactly as it's shown on the passport or ID card.

ID*

ID Number*

Please attach ID*

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

Height in Centimetres*

Weight in kilograms*

Marital Status*

Sex*

Male

Female

Profession*

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Medical conditions selected?

Yes

Declared pre-existing conditions

Your quotation was prepared based on the pre-existing conditions above, declared when filling out the quote request.

Health Questionare Scan*

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB, Max. files: 7.

Specific Health Questionnaire is required for Adeslas Seniors application.

You can download the pdf in this link: ADESLAS SENIORS

Please print a copy for every insuree, answer the questions, sign and upload here.

All fields are mandatory: location, date etc.

Tip: If you don´t have a scanner by hand, you can use any of the scanner apps available for your Apple or Android phone or tablet.

Health declaration

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.

Medical Conditions*

Have or have had cancer or a tumour

Diabetes

Hepatitis B, C, D

Cardiac, vascular, pulmonary, autoimmune or respiratory diseases

Metabolic (of the endocrine system) or digestive disorders

Rheumatological, bone or musculoskeletal conditions

Any diseases of the nervous system, the eyes or the ears

Haematological or blood clotting problem

Kidney, the urological and genitourinary tract, or gynaecological diseases

Infectious diseases

Transplants

Lesions, ongoing sequelae or complications from any diseases, congenital, chromosomal or hereditary disorders, malformations or accidents?

Ailments not fitting any mentioned above

I confirm that none of the applicants have any pre-existing health conditions to declare

Description*

Please supply further information. (making clear which of the insured persons it refers to if you are applying for several people)

Please select Annual Payment for ADESLAS Student insurance discount

Please select Annual Payment for DKV Student insurance discount

Monthly Total (€)*

Period of Coverage in Months*

Payment Amount*

Price:

Health Insurance Monthly

Price: 0.00 €

Health Insurance Quarter

Price: 0.00 €

Health Insurance Annual

Price: 0.00 €

ADESLAS Student Annual

Price: 0.00 €

DKV Student Annual

Price: 0.00 €

DKV Student R Annual

Price: 0.00 €

Annual receipt

Please send me annual bill

Mark this box if you want to receive the annual bill in your email, detailing all the operations done by the Association and its expenses.

GIDEA GESTIÓN INTEGRAL PRODUCT GRAN CONSUMO, S.L.U. does not act as a mediator or intermediary between the Client and the insurance agencies, nor does it manage their products. For this, each Client is assigned an agent of the company. Consequently, GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. is not a part of said contract, and the services provided by it will accrue fees that will be invoiced independently.
GIDEA GESTIÓN INTEGRAL PRODUCT GRAN CONSUMO, S.L.U. is a service company that is dedicated to facilitating access to families that come to reside in Spain and promotes the contracting of the necessary services to provide users with well-being. It has a continuous service of attention, in different languages, during the duration of the contracted service. Among others, the services offered are: administration services, processing of residence permits and additional documentation, search for housing, schools, contracting supplies, insurance and other services demanded by the group.
The signing of this document obliges the Client to pay the receipts issued by GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U., in accordance with the conditions expressed above. Said payment will be made on the agreed day, which will be considered for the purposes of this document as a “collection day”. It is expressly stated that, in case of not paying the receipt drawn on the same day of collection, the Client will have a period of five (5) days to pay, in addition to the receipt, the corresponding surcharge that arises from the Return costs, an issue for which express notification from GIDEA GESTIÓN INTEGRAL PRODUCT GRAN CONSUMO, SLU will not be necessary. This surcharge oscillates around five euros (€ 5.00), although depending on the entity this cost may be higher or lower, being, in any case, at the customer's expense to pay such amount, regardless of its value.
Once the five-day recovery period has elapsed without the Client having satisfied the amount owed and, where appropriate, the corresponding surcharge, GIDEA GESTIÓN INTEGRAL PRODUCT GRAN CONSUMO, S.L.U. to cause the withdrawal of the Client based on the breach of the obligations by the former. Therefore, it is expressly stated that the return of a single receipt, automatically and immediately entails the withdrawal from the group and any possible claims. In any case, non-payment by the Client will allow GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U to claim the debt that could have arisen through the channel it deems appropriate.
Once the Client has been unsubscribed from the group, they may request GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. reinstatement, upon payment of the amounts and amounts owed and a penalty surcharge of thirty euros (€ 30.00) for compensation expenses.
Once the Client cancels the group contract with GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. he will no longer receive the corresponding coverage. Said cancellation will take place, as stated above, in the event of non-payment or breach of obligations by the Client; due to the lack of veracity of the answers formulated in the contractual documents (Quote Request, health questionnaire and others), regardless of whether it is a consequence of fraud or negligence; and, in any case, at the discretion of the latter, expressed specifically and unequivocally by written communication within a period of one month before the corresponding receipt is issued. In any of the cases, when unsubscribed from the group GIDEA GESTIÓN INTEGRAL PRODUCT GRAN CONSUMO, S.L.U. the group will be released from any obligations that the insurance at their expense could establish.
GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, SLU, as policyholder, assumes the commitment to comply with each and every one of the obligations assigned to it and, especially, to make the monthly payment, the corresponding premium and, in general, of be up to date on everything related to the payments regarding Company. Regardless of the payment protocol that the Company may have, the Client undertakes to deposit to GIDEA GESTIÓN INTEGRAL PRODUCT GRAN CONSUMO, S.L.U. the amount corresponding to the agreed form of payment (annual, semi-annual, quarterly or monthly), so that it can be defrayed, month by month, the amounts that were generated as consideration for the contracted service.
The revision of prices of the health group will be annual and will take effect on January 1. GIDEA GESTIÓN INTEGRAL PRODUCT GRAN CONSUMO, S.L.U. The new conditions will apply on January 1 of each annuity, leaving the client to accept or not such modifications. In the event that the Client does not specifically express his rejection of the modifications within thirty days of said application, it will be understood as tacitly renewed.
GIDEA GESTIÓN INTEGRAL PRODUCT GRAN CONSUMO, S.L.U. will make available to the client the invoices that accrue for the services provided at the client's request by email that will be addressed to the following address: office@gideagestion.com
In this form you do have a checkbox available if you prefer to receive in your email the corresponding invoices and receipts accrued for the provision of services of this Company. In any case, it may be requested at any time as indicated in the previous paragraph.
The whole text of the present Contract have been written in Spanish and English, both versions being deemed authentic, but for legal purposes in a case of discrepancy shall prevail the text in Spanish.

CONDICIONES DE SERVICIOS
GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. no actúa como mediador ni intermediario entre el Cliente y las agencias aseguradoras, ni gestiona sus productos, para ello cada Cliente tiene asignado un agente de la compañía. En consecuencia, GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. no forma parte de dicho contrato, y los servicios prestados por la misma devengarán honorarios que se facturarán de forma ajena e independiente.
GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. es una empresa de servicios que se dedica a facilitar el acceso a familias que vienen a residir a España y promueve la contratación de los servicios necesarios para dotar de bienestar a los usuarios. Posee un servicio continuo de atención, en diferentes idiomas, durante la duración del servicio contratado. Entre otros, los servicios que ofrece son: servicios de administración, tramitación de permiso de residencia y documentación adicional, búsqueda de vivienda, colegios, contratación de suministros, seguros y otros servicios demandados por el colectivo.
La firma del presente documento obliga al Cliente al abono de los recibos girados por GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U., conforme a las condiciones expresadas con carácter precedente. Dicho pago se realizará el día pactado, que será considerado a efectos del presente documento como “día de cobro”. Se hace constar de forma expresa que, en caso de no abonar el recibo girado el mismo día de cobro, el Cliente tendrá un plazo de cinco (5) días para abonar, además del recibo, el correspondiente recargo que se origine con motivo de los gastos de devolución, cuestión para lo cual no será necesaria notificación expresa por parte de GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. Dicho recargo oscila en torno a los cinco euros (5,00 €), si bien dependiendo de la entidad dicho coste puede ser superior o inferior, siendo, en todo caso, a costa del cliente sufragar tal importe, con independencia de su valor.
Transcurrido el periodo de recobro de cinco días sin que el Cliente haya satisfecho la cuota adeudada y, en su caso, el correspondiente recargo, se procederá por GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. a causar la baja del Cliente en base al incumplimiento de las obligaciones por parte de aquél. Por tanto, se hace constar expresamente que la devolución de un único recibo conlleva, de forma automática e inmediata, la baja del colectivo y la reclamación. En todo caso, el impago por parte del Cliente permitirá a GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U reclamar la deuda que se hubiera podido originar por el cauce que estime conveniente.
Una vez el Cliente haya sido dado de baja del colectivo podrá solicitar a GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. la reincorporación al mismo, previo pago de los importes y cantidades adeudados y de un recargo de penalización de treinta euros (30,00 €) por el concepto de gastos de compensación.
Una vez el Cliente cause baja respecto del colectivo GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. dejará de recibir la correspondiente cobertura. Dicha baja tendrá lugar, tal y como se ha hecho constar anteriormente, en caso de impago o incumplimiento de las obligaciones por parte del Cliente; ante la falta de veracidad de las respuestas formuladas en los documentos contractuales (Solicitud, cuestionario de salud y otros), con independencia de que la misma sea consecuencia de dolo o negligencia; y, en todo caso, por voluntad de éste, manifestada de forma expresa e inequívoca mediante comunicación por escrito en un plazo de un mes antes de que sea girado el recibo correspondiente. En cualquiera de los casos, producida la baja del colectivo GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. quedarán liberadas de cuantas obligaciones pudiera establecer el seguro a su cargo.
GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U., como tomador del seguro, asume el compromiso de cumplir con todas y cada una de las obligaciones que tiene asignadas y, especialmente, de efectuar el pago mensual, la prima que corresponda y, en general, de estar al día en todo lo relativo a pagos respecto de la Compañía. Con independencia del protocolo de pago que pudiera tener la Compañía, el Cliente se compromete a depositar a GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. el importe correspondiente a la forma de pago pactada (anual, semestral, trimestral o mensual), de forma que pueda ir sufragando, mes a mes, las cantidades que se fueran generando como contraprestación por el servicio contratado.
La revisión de precios del colectivo de salud será anual y tendrá efecto el día uno de enero. GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. aplicará las nuevas condiciones el uno de enero de cada anualidad, quedando en manos del cliente el aceptar o no tales modificaciones. En caso de que el Cliente no manifieste expresamente su rechazo a las modificaciones en un plazo de treinta días desde dicha aplicación, se entenderá renovado de forma tácita.
GIDEA GESTIÓN INTEGRAL PRODUCTO GRAN CONSUMO, S.L.U. pondrá a disposición del cliente las facturas que se devenguen por los servicios prestados a petición del cliente mediante correo electrónico que habrá de dirigir a la siguiente dirección: oficina@gideagestion.com
Marque la casilla correspondiente en el formulario si desea recibir en su correo electrónico las correspondientes facturas y recibos devengadas por la prestación de servicios de esta empresa. En todo caso, podrá solicitarse en cualquier momento conforme a lo indicado en el párrafo anterior.

I agree to the Terms of Service

Data Protection*

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.

Data sharing*

I give consent to GIDEA to complete my data on my behalf in the insurer's database and within their app.

Signature*

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Order nr

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Affiliate ID

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Special Conditions to sign?

Yes

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Attach a file: Special Conditions to Sign*

Special Terms Signed

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Insurance provider specific conditions, exclusions etc.

Client receives this text with a prompt to follow further with their application and receive the payment information.