Adeslas Contract "*" indicates required fields PERSONAL DATA OF THE POLICY HOLDERName* Full legal first and middle names Full legal last name(s) Tax ID No.* DNI, NIE, or Passport DETAILS OF THE PERSON TO BE INSUREDName* Full legal first and middle names Full legal last name(s) Tax ID No.* DNI, NIE, or PassportPlease attach the passport or NIE*Accepted file types: jpg, jpeg, png, pdf, Max. file size: 3 MB.Please attach a scan or good quality photo of the documentDate of birth* DD dash MM dash YYYY Age nr*Gender* Weight in kilograms* Height in centimeters* Relationship with the applicant* Contact InformationPhone*Email* Address* Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands DETAILS OF THE LEGAL REPRESENTATIVEName Full legal first and middle names Full legal last name(s) Tax ID No. DNI, NIE, or Passport Policy Date of Effect* DD dash MM dash YYYY HEALTH-RELATED INFORMATION1. Do you suffer or have you suffered any illness in the last five years?* Yes No Please specify which, date, treatment and evolution* Have the illnesses you have suffered until now left any lesions or sequelae? Yes No Please specify* 2. Have you been operated on or admitted into hospital at any time?* Yes No 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 No Please specify which, date, treatment and evolution* 5. Have you suffered any o traumatism or accident?* Yes No Please specify date, treatment and sequelae* 6. Are you currently under medical control or following any kind of treatment?* Yes No Please specify which* a) Do you know whether you will need any study or treatment within the next year?* Yes No Please specify which* b) Will you need to be admitted into hospital within that time period?* Yes No Please state the reason* 7. Are you or have you been a smoker?* Yes No Please specify amount per day* Do you consume or have you consumed alcoholic drinks regularly?* Yes No Please specify amount per day and type of drinks* Do you consume or have you consumed narcotics?* Yes No Please specify the type of products* HiddenNumber of BeneficiariesPlease enter a number from 1 to 7.Hiddenthis Beneficiary nrHiddenBenific. differenceif "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)Signature* Reset signature Signature locked. Reset to sign again HiddenQR entry Hiddenaffwp_ref HiddenAffiliate ID Hiddenh1Hiddenh2Hiddenh3Hiddenh4Hiddenh5Hiddenh6Hiddenw1Hiddenw2Hiddenw3Hiddenw4Hiddenw5Hiddenw6Hiddenbirth1 Day Month Year Hiddenbirth2 Day Month Year Hiddenbirth3 Day Month Year Hiddenbirth4 Day Month Year Hiddenbirth5 Day Month Year Hiddenbirth6 Day Month Year Order nrHiddenCompañia Δ