Health Insurance for Non-EU Citizens [HI]

Name*

First NameLast Name
Date of Birth*

DayMonthYear
Gender*
Nationality*
Job (Occupation)*
Phone Number*

Area CodePhone Number
Email:*
Address
Postal Code
District
Are you an existing client?*

ΝοYes - please give details (e.g. policy number, ID, account)
Your Medical History:

(If your answer to the following question is Yes , we will revert back to you requesting additional information)
Have you been provided with, in the last five years, and/or are you currently taking any prescription drugs or medication?*

NoYes
Have you been admitted to a hospital, clinic or nursing home in the last five years?*

NoYes
Do you suffer from a chronic medical condition or from a known disability or recurrent injury or illness?*

NoYes
Important Notes:

1. Please note that this form is for quotation purposes only. If you wish to proceed with a contractual agreement you will be required to submit a proposal form. 2. Our quotation will be based on the information you have submitted, therefore, any alterations and/or misleading information, will cause a revision to the quotation accordingly. 3. We have collected only personal data you have voluntarily provided to us and which are processed solely for the purpose of risk assessment and preparation of this quotation.Where additional information is sought, you will be informed at the time of the data collection. If we do not conclude with a contract any personal data collected will be destroyed immediately. However, in case that you choose us for your policy, we are obliged by law to retain your personal data for a period of at least 13 (thirteen) years after termination.
Should be Empty:

Your Medical History:

Important Notes: