Insurance Application
MA RK IN TH E CA SE OF TRA N SFER Incorporation
Application number Policy number
Modification
Transfer
Sub-group number
Certificate number
Delegation
Effective date
Expiry
Remittance of documentation
Campaign
Mediator Code 1 ____________________________________________________________
Customer
Mediator
Delegation
Zone
KAM
Group
Mediator Code 2 ____________________________________________________________
Transfer Data - (TO BE FILLED IN ONLY IN CASES OF TRANSFER) (1) No. of Policy of Origin (2)
Return of premium
Certificate No. (2)
Cancellation of policy in full
Cancellation of the insured transferred (REMAINDER OF THE INSURED MAINTAINED)
Policyholder Data Surname and First Name _____________________________________________________________________________________ NIF/NIE ______________________________________
Address: Type of Roadway (4)
Street name ____________________________________________________________________ Street number _________ Floor ________
Postal Code ____________________ Town or City ______________________________________________________________________________________________________________
Profession (4)
Date of birth_________________________________________________ Marital Status (4)
Gender
Male
Female
Telephone no._____________________________ Mobile phone _____________________________ E-mail address _______________________________________________________ Bank Account Language of documentation (4) Form of payment (4) Number Additional Policyholder data (To be filled in ONLY IF POLICYHOLDER IS THE INSURED) (IF THIS SECTION IS FILLED IN IT IS NOT NECESSARY TO FILL IN THE DATA OF POLICYHOLDER AS THE INSURED)
Have you previously been a customer of the Company?
No. of Policy of Origin
Yes
No
Do you request Exceptions from Exclusions? (5)
Yes
No
Participating Providers
Certificate no.
Insured Data 1)
Surname and First Name _________________________________________________________________________________ NIF/NIE _______________________________________ Address __________________________________________________________________ Date of birth____________________________________ Profession (4)
Postal Code ________________ Town or City __________________________________ Gender
Male
Female Relationship (4)
Medical Team
Telephone number ___________________________ Mobile phone ___________________________ E-mail address____________________________________________________ Have you previously been a customer of the Company?
ONLY IN THE CASE OF TRANSFER:
2)
Yes
No
Are you requesting exemption from the claims waiting period? (5)
No. of Policy of Origin (3)
Yes
No
Certificate no. (3)
Surname and First Name _________________________________________________________________________________ NIF/NIE _______________________________________ Address __________________________________________________________________ Date of birth____________________________________ Profession (4)
Postal Code ________________ Town or City __________________________________ Gender
Male
Female Relationship (4)
Medical Team
Telephone number ___________________________ Mobile phone ___________________________ E-mail address____________________________________________________ Have you previously been a customer of the Company?
ONLY IN THE CASE OF TRANSFER:
3)
Yes
No
No. of Policy of Origin
Are you requesting exemption from the claims waiting period? (5)
(3)
Certificate no.
Yes
No
(3)
Surname and First Name _________________________________________________________________________________ NIF/NIE _______________________________________ Address __________________________________________________________________ Date of birth____________________________________ Profession (4)
Postal Code ________________ Town or City __________________________________ Gender
Male
Female Relationship (4)
Medical Team
Telephone number ___________________________ Mobile phone ___________________________ E-mail address____________________________________________________ Have you previously been a customer of the Company?
ONLY IN THE CASE OF TRANSFER:
4)
Yes
No
No. of Policy of Origin
Are you requesting exemption from the claims waiting period? (5)
(3)
Certificate no.
Yes
No
(3)
Surname and First Name _________________________________________________________________________________ NIF/NIE _______________________________________ Address __________________________________________________________________ Date of birth____________________________________ Profession (4)
Postal Code ________________ Town or City __________________________________ Gender
Male
Female Relationship (4)
Medical Team
Telephone number ___________________________ Mobile phone ___________________________ E-mail address____________________________________________________ Have you previously been a customer of the Company?
ONLY IN THE CASE OF TRANSFER:
Yes
No
Are you requesting exemption from the claims waiting period? (5)
No. of Policy of Origin (3)
Yes
No
Certificate no. (3)
PRODUCT
OBSERVATIONS
Additional information per insured
S.OS.F.01 I/05
Application Decision:
Insured 1
ACCEPTED
REJECTED
Insured 2
EXCLUSIONS
Insured 3
Insured 4
(1), (2), (3), (4) and (5) See instructions on reverse side.
In accordance with that stated in the section “'TREATMENT AND TRANSFER OF PERSONAL DETAILS” which appears on the reverse side of this insurance request, please mark the corresponding box/es if you do not wish to be sent information and/or you do not want your details to be transferred as stated. I do not accept the use of my personal details for promotional purposes. I do not want my details to be given to third parties.
Date___________________________ Signature _________________________________
SegurCaixa Adeslas, S.A. de Seguros y Reaseguros - Juan Gris 20-26, 08014 Barcelona (Spain). Registered in the Commercial Registy of Barcelona, book 20481, sheet 130, page B6492. VAT No.:A28011864
Copy for the Company
Policyholder