Life Insurance Quote Request

1Capital

2Policyholder

3Insuree

4Beneficiaries

Basic Information

Profession*

Risk Activity*

Date of Birth*

dd-mm-yyyy

Date of Policy Start*

dd-mm-yyyy

Employment*

Employed

Self-employed

Retired

Policy Guarantees Selected

Death from any cause

It is the main life insurance guarantee. Beneficiaries receive 100% of the contracted capital if death occurs independently from the cause.

Capital*

The Insured will be required to provide a medical report to support their insurance application.

Double death accident

Double capital in death by accident

When the cause of death is an accident, the beneficiary will receive double the contracted capital.

Death by Accident*

Permanent and absolute disability

It implies, whether due to illness or accident, the insured's inability to perform any professional activity. In this case, the insuree will be the beneficiary of the policy.

Permanent disability*

Double capital in disability by accident

Double capital in permanent and absolute disability by accident

When the death is caused by an accident, the beneficiary will receive double the capital contracted.

Double in disability by accident*

Are you the one insured?*

Yes

No, I'm just the policyholder

Policyholder Information

Name*

First Last

Sex*

Male

Female

Date of Birth Policyholder*

Marital status*

Nationality*

Document*

number*

Please attach policyholders 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

Address*

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

Phone*

Email*

Insuree Information

Name*

First Last

Sex*

Male

Female

This field is hidden when viewing the form

Date of Birth*

dd-mm-yyyy

Marital status*

Nationality*

Document*

number*

Please attach insured 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

Address*

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

Phone*

Email*

Health Information

Height (cm)*

Weight (kg)*

incapacitado

I am totally or partially disabled, I have a disabling condition, or I am in the process of obtaining disability status

Details*

actividad interrumpida

During the last 3 years my work has been interrupted for more than 10 days in a row as a result of an illness or accident

Date*

Motive*

baja laboral

I am currently on work or medical leave

Details*

alcohol

Alcohol consumption

Quantity*

Type*

Frequency*

tabaco

Smoking

Quantity*

Type*

Frequency*

drogas

Drug use

Quantity*

Type*

Frequency*

patologias

I suffer or have suffered from any of the following diseases: heart, circulatory, respiratory, neurological, mental, hepatic, digestive, rheumatologic, renal, urogenital insufficiency, cerebrovascular accident, cancer / tumor, degenerative disease of the nervous system, syndrome or malformation congenital, HIV / AIDS, hypertension, cholesterol, diabetes or hernia

Date*

Pathology*

Center where the treatment was received*

Basic Information

Policy Guarantees Selected

Policyholder Information

Insuree Information

Health Information

Add a new beneficiary