SANITAS HEALTH INSURANCE APPLICATION

Policy holder full name: *

Policy holder Email: *

example@example.com

Policy holder gender *

Male Female

Policy holder cell / mobile number: *

Country code Phone Number

Policy holder year of birth *

Policy holder month of birth *

Policy holder date of birth *

Policy holder Nationality: *

Policy holder passport Nº: *

Select the plan required: *

Top 7 options are visa / residency compatible

Policy start year *

Starting month for policy *

All policies start the 1st of the month

Select optional policy add-on's below:

Note: Price's quoted will most likely not include any of these of these add-on's

Policy add-on´s

BLUA - Digital for online appointments. €10 per person €20 family / month / PP Pharmacy re-reimbursement. €4 Euro / Month / PP Traffic and work accidents. €2.5 Euro / Month / PP

Repatriation add-on

Do you require this policy supplement? This is very often a visa requirement for countries outside of Europe (with a few exceptions) this can be added for 3 Euros a month - 36 Year per person year.

Bank account details for Eurozone (SEPA) banks ONLY:

Note: Please leave blank, if you do not yet have an account in Spain or another European country. Anual payment by card or wire transfer will be applied.

Policies without a SEPA zone account require annual payment in full. If you do have European (SEPA) bank account we can apply Monthly, Quarterly or Bi-Annual payment.

If you do not have a useable bank account please select Annual payment to proceed.

Payment frequency *

Annual payment Six Monthly Quarterly Monthly

International Euro Bank Account

referred to as IBAN

SWIFT / BIC CODE

Required for International accounts

Passport copies for policy holder and all applicants:

Please scan or photo the principal page/s of your passport (the main page inc. the photo ID and passport Nº and signature etc) and upload all using the browse option below. NOTE: VISA stamped pages etc are note required.

Passport/s main page inc. Photo ID for Policy holder and all insured's *

Browse Files

You may upload multiple files here:

POLICY HOLDER ADDRESS

(Spanish address ONLY)

Note: Please leave blank, if you do not yet have a Spanish address we will use our office address until you have one.

For apartments and urbanistations use: Block, Staircase, Floor, Flat as applicable.

Street:

No.

Block:

Staircase:

Floor:

Flat:

Town/City:

Postcode:

Province:

Please answer the data protection question below Yes or No as you prefer.

1.

I agree to process my personal data to promote Sanitas or third-party company products and services, including marketing communications via electronic means or equivalent sent by Sanitas, even if I do not take out the insurance.

1. *

Yes No

2.

I agree to transfer and process my personal data by Sanitas group companies for scientific and / or statistical research purposes and marketing purposes, in addition to third-party collaborating companies identified in Additional Information, in order to send me marketing information related to financial products and services, insurance, social and healthcare and/ or health or wellness products and services,including marketing communications via electronic means

2. *

Yes No

3.

I agree to process my personal data for the purpose of Sanitas analysing my interests and needs based on the data I provide, including, but not limited to, my health data, personal data generated as a consequence of a service provided by Sanitas or that Sanitas has obtained via other means; this processing may include automated decision making.

3. *

Yes No

SANITAS HEALTH INSURANCE

Policy type & holder details

INSURED APPLICANT Nº 1

INSURED APPLICANT Nº 2

INSURED APPLICANT Nº 3