Insured:
Name:
Sir Name:
Email:
NIF:
Adress:
Town
P.C.:
Province:
Sex:
Male Female
Date of birth:
(day/month/year)
Occupation:
Marital status
Single Married Divorced Widow
Number of children:
Weight:
Height:
Declarations on behalf of the insured:
Do you drive a motor bike or a bike?:
Less than 50 cc Up to 125 cc Up to 250 cc More than 250 cc
Do you suffer from any physical disability?:
Yes No Which?
Do you do any dangerous sport?:
Heart attack:
Do you suffer from or have you ever suffered from a heart desease?:
Have you had any interventions due to this in the past:
Are there any examples of death in your family because of this?:
Yes No
Cover Plan:
Yes
No
Insured amount
Basic-death:
Accident leading to death (Double amount) Fallecimiento por accidente (Doble capital):
Traffic accident leading to death (Triple amount):
Death combined with an accident (only women):
Death by heart attack:
Death of a partner (Only women ):
Complete or permanent disability, for whatever reason:
Parcial incapacity:
Disability due to an accident (Double Amount):
Disability due to a traffic accident (Triple Amount):
Temporary work incapacity. Exemption 7 days:
Payment for hospitalization -surgical:
Medical assistance - Accident:
Children with incapabilities (Only women):
Vida