INSURANCE REQUEST

CONTRACT PRODUCT

TARIFF:

SECTOR:

PRODUCT:

COPAYMENT:

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:

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:

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) ...

DATA CONTROLLER: Nueva Mutua Sanitaria del Servicio Médico, a Fixed Premium Insurance Company, with VAT number V86444965 (Nueva Mutua Sanitaria), registered with the Directorate General of Insurance and Pension Funds under number M0380.

DATA PROTECTION OFFICER: Nueva Mutua Sanitaria has a Data Protection Officer, to whom you may address any issues regarding the processing of your personal data, by contacting the following email address: dpo@nuevamutuasanitaria.es

PURPOSE OF PROCESSING: Your data will be processed for the purpose of formalizing the insurance contract requested by you and executing the guaranteed healthcare provision. Additionally, your personal data, excluding your health data, may be processed by Nueva Mutua Sanitaria to send you commercial communications about our insurance products, as well as services and offers related to the health and wellness sector marketed by the company Tecnologías de la Salud y Bienestar, S.L., belonging to the Nueva Mutua Sanitaria Group, through any means permitted by law, including email or any other electronic communication means you have provided us with.
If you do not wish for us to process your data to inform you about insurance products and services related to health and wellness marketed by the Nueva Mutua Sanitaria Group, you can send us an email at any time objecting to the processing of your data for this purpose, to the following email address: protecciondedatos@nuevamutuasanitaria.es.
If the provided data belongs to a third party (insured party different from the policyholder), the provider guarantees that they have informed the owners of their communication to the Mutual, under the terms and for the exclusive purposes set out in this clause, as well as of their rights (detailed below).
Your data will not be processed by Nueva Mutua Sanitaria for automated decision-making, including profiling, that could produce legal effects on you or significantly affect you individually.

LEGAL BASIS: The legal basis for the processing is the existence of the pre-contractual relationship arising from the insurance application as well as the legitimate interest of the data controller to send commercial communications about its insurance products and services related to health and wellness offered by the Nueva Mutua Sanitaria Group.

DATA RECIPIENTS: Data necessary for risk assessment and premium pricing will not be transmitted to any third party outside of Nueva Mutua Sanitaria. Data necessary for the proper provision of contracted coverage may be transmitted between Nueva Mutua Sanitaria and doctors, hospitals, or other institutions or individuals identified as providers of healthcare services, solely for the strict compliance with such services.

RIGHTS: We remind you that you can exercise your rights of access, rectification, limitation of processing, erasure, objection, and the right to data portability. To exercise these rights, you can contact us via email: protecciondedatos@nuevamutuasanitaria.es, indicating "Data Protection Rights" in the subject line, or, if you prefer, by postal mail addressed to Nueva Mutua Sanitaria del Servicio Médico, Calle Villanueva nº 14, 4º, 28001 Madrid, specifying which right you wish to exercise and including a photocopy of your ID card or equivalent valid official identification document.

ADDITIONAL INFORMATION: For more information about our data protection policy, you can consult the following website: http://www.nuevamutuasanitaria.es/politica-de-proteccion-de-datos

ACCEPTANCE OF THE POLICY IS CONDITIONED ON THE ACCEPTANCE OF THIS APPLICATION BY NUEVA MUTUA SANITARIA DEL SERVICIO MÉDICO, A FIXED PREMIUM INSURANCE COMPANY. Nueva Mutua Sanitaria may cancel the Policy within one month from the knowledge of the reservation or inaccuracy of the declarant when completing the questionnaire, but this right cannot be based on the insurer's lack of knowledge of the insured's health data unrelated to the preceding questions. If there is fraud or gross negligence in completing this questionnaire, Nueva Mutua Sanitaria is hereby released from all obligations established by the insurance. (Article 10 Insurance Contract Law).

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 contratacion@nuevamutuasanitaria.es  91 290 90 90