INSURANCE REQUEST

ESTUDIANTES i-Study SPAIN

The insurance registration date, must coincide with your arrival date in Spain
START DATE:  
INSURANCE DURATION:
HOLDER INFORMATION
* The holder must be of legal age (+18 years)
NAME:
SURNAME:
SURNAME 2 :
TITLE:
NIF/ NIE/ PASSPORT:
Accepts pdf, jpg and png files.
COUNTRY OF ORIGIN:
STATE:
TOWN:
POSTAL CODE:
TYPE OF ROAD:
ADDRESS:
NUMBER:
PORTAL:
STAIRCASE:
FLOOR:
DOOR:
ADDITIONAL DATA TO THE ADDRESS:
E-MAIL:
MOBILE PHONE NUMBER:* A Spanish mobile number is required to complete this form.

ANOTHER PHONE NUMBER :

THE HOLDER, WISH BE INSURED?* The holder must be of legal age (+18 years)
THE HOLDER, WISH HAVE THE SAME BENEFITS ADDRESS (CARE AT HOME)?
DIRECT DEBIT PAYMENT
CREDIT CARD HOLDER:
NIF/ NIE/ PASSPORT:
Accepts pdf, jpg and png files.
PAYMENT METHOD:
PERIODICITY OF PAYMENTS:

* Payment periodicity must be yearly as a requirement of embassies to process the visa

BENEFITS ADDRESS (CARE AT HOME)
COUNTRY OF ORIGIN:
STATE:
TOWN:
POSTAL CODE:
TYPE OF ROAD:
ADDRESS:
NUMBER:
PORTAL:
STAIRCASE:
FLOOR:
DOOR:
ADDITIONAL DATA TO THE ADDRESS:
E-MAIL:
PHONE NUMBER:

INSURED'S INFORMATION (1)
NAME:
SURNAME:
SURNAME2 :
TITLE:
NIF/ NIE/ PASSPORT:
Accepts pdf, jpg and png files.
BIRTHDATE:
GENDER:
CIVIL STATUS:
E-MAIL:
PHONE NUMBER:

WHAT'S THE RELATION WITH THE HOLDER?
HEALTH QUESTIONNAIRE
THIS HEALTH QUESTIONNAIRE IS VALID FOR 3 MONTHS EXCEPT FOR THOSE ILLNESSES THAT OCCUR AFTER THE DATE OF ITS SIGNATURE
WEIGHT:
HEIGHT:

INDICATE IF YOU HAVE OR HAVE HAD ANY OF THESE DISEASES:
  • ANY TYPE OF ONCOLOGICAL PROCESS IN THE LAST 5 YEARS.
  • DISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS: Multiple sclerosis, parkinson's, alzehimer's, epilepsy, paraplegia.
  • MENTAL ILLNESSES: Schizophrenia, bipolar disorders, mental retardation, conduct disorders nutritional.
  • ENDOCRINE SYSTEM DISEASES: Type i diabetes mellitus, morbid obesity, alterations corticosadrenals.
  • DISEASES OF THE OSTEMIOARTICULAR SYSTEM AND CONNECTIVE TISSUE: Systemic lupus, rheumatoid arthritis, ankylopoietic spondylitis, dermatomyositis, muscular dystrophies, disc herniation, scoliosis, and lumbociatalgia.
  • CONGENITAL AND CHROMOSOMAL ANOMALIES.
  • SYSTEMIC DISEASES: FIBROMYALGIA.
  • DISEASES OF THE CIRCULATORY SYSTEM: Ischemic heart disease, cerebrovascular diseases, atherosclerosis, malignant hypertensive disease, heart failure, cardiomyopathy, rhythm disorders, vascular diseases.
  • DISEASES OF THE RESPIRATORY SYSTEM: Chronic obstructive disease, fibrosis pulmonary, pneumonitis, granulomatosis, pneumoconiosis, histiocytosis.
  • DIGESTIVE AND GENITOURINARY DISEASES: Ulcerative colitis, crohn's disease, liver diseases chronicles, chronic renal insufficiency.
  • DISEASES OF THE BLOOD AND HEMATOPOIETIC ORGANS: Hemophilia, sickle cell anemia, alterations of the coagulation.
COMMENTS ABOUT THIS REQUEST
STUDENT'S DOCUMENTATION
COLLEGE ADMISSION LETTER / REGISTRATION FEE
Accepts pdf, jpg and png files.
PRIVACY POLICY

DATA CONTROLLER: Nueva Mutua Sanitaria del Servicio Médico, Mutual Insurance Company with Fixed Premium, with Tax Identification Number (CIF) ...

DATE OF REQUEST EXECUTION:
MADRID, on june 22, 2025.