Adeslas Contract

"*" indicates required fields

PERSONAL DATA OF THE POLICY HOLDER

Name*

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

Tax ID No.*

DNI, NIE, or Passport

DETAILS OF THE PERSON TO BE INSURED

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*

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

Please attach a scan or good quality photo of the document

Date of birth*

DD dash MM dash YYYY

Age nr*

Gender*

Weight in kilograms*

Height in centimeters*

Relationship with the applicant*

Contact Information

Phone*

Email*

Address*

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

DETAILS OF THE LEGAL REPRESENTATIVE

Name

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

Tax ID No.

DNI, NIE, or Passport

Policy Date of Effect*

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 dash MM dash YYYY

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 slash MM slash YYYY

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*

Number of Beneficiaries

Please enter a number from 1 to 7.

this Beneficiary nr

Benific. difference

if "0" send supp notif+ create adhesion + send to payment

Amount*

Period of Coverage in Months*

Monthly Price*

Total price for all applicants

How you will pay*

Wire Transfer (Wise)

Credit / Debit Card

The undersigned states, under their responsibility, that their answers to the questions made are truthful and complete, authorising SegurCaixa Adeslas to undertake any verification deemed convenient on the origin and evolution of the illnesses or ailments that may, given the case, require assistance under this Policy. The undersigned authorises the Company, if any illness has been suffered, to contact the intervening doctors.

SegurCaixa Adeslas may reach a decision on the Policy within a month from the time it knows of the deponent’s reservations or inaccuracies in filling in the questionnaire, although this right can not be based on the Insurer’s lack of knowledge on the Policy Holder’s state of health information that is not included in the above questions.

If fraud or serious fault exits in filling in this questionnaire, SegurCaixa Adeslas shall in any case and from now on be freed of the obligations established for it by the insurance policy (Art. 10 Law on Insurance Contracts)

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.

Signature*