INSURANCE REQUEST

SEGURO DE SUBSIDIO POR HOSPITALIZACIÓN 60

START DATE:  
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 :

OCCUPATION:
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)?
THE HOLDER, WILL BE THE PAYER?
NUMBER OF INSURED:
DIRECT DEBIT PAYMENT
BANK ACCOUNT HOLDER:
NIF/ NIE/ PASSPORT:
Accepts pdf, jpg and png files.
PAYMENT METHOD:
COUNTRY BANK ACCOUNT:
BANK ACCOUNT NUMBER:

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?
IS ATTACHED THE HEALTH QUESTIONNAIRE?:
HEALTH QUESTIONNAIRE
WEIGHT:
HEIGHT:

1. INDICATE IF YOU HAVE OR HAVE HAD ANY OF THESE DISEASES
  • STROKE
  • CORONARY HEART DISEASE
  • CARDIOMYOPATHY (Cardiac arrhythmias, tachycardias)
  • ARTERIOSCLEROSIS
  • ARTERIAL HYPERTENSION
  • CORONARY ARTERY BYPASS GRAFT, ABDOMINAL AORTIC GRAFT OR LIMB ARTERIAL GRAFTS
  • HEART FAILURE
  • ARTERIAL ANEURISMS
  • CANCER ANY TYPE OR LOCATION, INCLUDING POLYPS AND TUMORS IN THE LAST 5 YEARS
  • LEUKEMIA, LYMPHOMAS IN THE LAST 5 YEARS
  • MYELODYSPLASTIC SYNDROMES
  • MAJOR THALASEMIA
  • BLEEDING DISORDER (Hemophilia, factor deficit)
  • LIVER DISEASES, HEPATIC CIRRHOSIS, HEREDITARY HEMOCHROMATOSIS, INFLAMMATORY BOWEL DISEASE
  • INSULIN-DEPENDENT DIABETES
  • EPILEPSY
  • EYE DISEASE: GLAUCOMA, CATARACTS, RETINAL DISEASE OR OTHERS
  • OBESITY SURGERY
  • COPD, CHRONIC BRONCHITIS, BRONCHIECTASIAS, PULMONARY FIGROSIS, HISTIOCITOSIS
  • PARKINSON
  • SPINAL CORD INJURY
  • MOTOR NEURONE INJURIES
  • IRREVERSIBLE MYELITIS
  • MULTIPLE SCLEROSIS
  • DEMENCIES
  • MYASTHENIA GRAVIS
  • CHRONIC FATIGUE SYNDROME
  • FIBROMYALGIA
  • DISC HERNIATION (Whether previously treated or not)
  • ANY TYPE OF ARTICULAR AND / OR BONE PROSTHESIS
  • SCHIZOPHRENIA
  • BIPOLAR DISORDERS
  • EATING DISORDERS
  • DEPRESSION (In treatment)

2. INDICATE IF YOU HAVE OR HAVE HAD ANY OF THESE DISEASES
  • VARICOSE VEINS
  • THYROID PATHOLOGY
  • ASTHMA
  • CELIAC DISEASE
  • GOUT (Hyperuricemia)
  • HIATO'S HERNIA
  • KIDNEY STONES
  • GALLSTONES
  • MIGRAINE
  • PSORIASIS
  • PEPTIC ULCUS (stomach or duodenal ulcer)

3. HAVE YOU BEEN GOT ANY SURGICAL INTERVENTION IN ANY OCCASION OR HAVE YOU BEEN HOSPITALIZED? IF SO, WHY? WHEN? DO YOU SUFFER AFTERMATHS?

4. HAVE OR HAVE HAD ANY PHYSICAL DEFECTS, DEFORMITY, HANDICAP, DISABILITY OR CONGENITAL INJURY? IF SO, INDICATE THE DEGREE AND TYPE OF RECOGNIZED OR PROCESSING DISABILITY OR HANDICAPPINESS.

5. ARE YOU CURRENTLY UNDER MEDICAL TREATMENT OR MONITORING? WHICH? WHY REASON?

6. ARE YOU PENDING FOR DIAGNOSIS OR FOR RECEIVING MEDICAL RESULTS? WHICH ONE? WHY?

7. DO YOU SUFFER FROM ANY DISEASE, HEALTH CONDITION, OR SYMPTOM NOT MENTIONED ABOVE THAT MAKES YOU THINK YOU WILL NEED TO CONSULT WITH A DOCTOR OR RECEIVE MEDICAL ASSISTANCE SOON (FOR EXAMPLE, IN CASE OF PREGNANCY)? IF SO, WHICH?
COMMENTS ABOUT THIS REQUEST
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 15, 2025.