Insbrok - GIDEA MESAG Seguros
  • Spanish

Adeslas Contract

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PERSONAL DATA OF THE POLICY HOLDER

Name*
DNI, NIE, or Passport

DETAILS OF THE PERSON TO BE INSURED

Name*
DNI, NIE, or Passport
Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.
Please attach a scan or good quality photo of the document
DD dash MM dash YYYY

Contact Information

Address*

DETAILS OF THE LEGAL REPRESENTATIVE

Name
DNI, NIE, or Passport
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?*
Have the illnesses you have suffered until now left any lesions or sequelae?
2. Have you been operated on or admitted into hospital at any time?*
DD slash MM slash YYYY
4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?*
5. Have you suffered any o traumatism or accident?*
6. Are you currently under medical control or following any kind of treatment?*
a) Do you know whether you will need any study or treatment within the next year?*
b) Will you need to be admitted into hospital within that time period?*
7. Are you or have you been a smoker?*
Do you consume or have you consumed alcoholic drinks regularly?*
Do you consume or have you consumed narcotics?*
Please enter a number from 1 to 7.
if "0" send supp notif+ create adhesion + send to payment
Total price for all applicants
How you will pay*
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*
Renewals and Refunds*
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birth1
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birth2
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birth3
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birth4
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birth5
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birth6
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