Documentation

Product

Selected product *

Message

Policy holder

Name *

Last name *

DNI / NIE *

Address

Nationality *

Date of birth *

Post code *

Email *

Fax

Telephone *

Call back time *

Number of persons to be insured * 1 2 3 4 5 6

Insured party 1

Name insured party

Date of birth

Sex * Choose Male Female

Do you have or have you had: serious illnesses/surgery, cancer, heart condition, diabetes, transplant, etc.? * Choose Yes No

Insured party 2

Name insured party

Date of birth

Sex * Choose Male Female

Do you have or have you had: serious illnesses/surgery, cancer, heart condition, diabetes, transplant, etc.? * Choose Yes No

Insured party 3

Name insured party

Date of birth

Sex * Choose Male Female

Do you have or have you had: serious illnesses/surgery, cancer, heart condition, diabetes, transplant, etc.? * Choose Yes No

Insured party 4

Name insured party

Date of birth

Sex * Choose Male Female

Do you have or have you had: serious illnesses/surgery, cancer, heart condition, diabetes, transplant, etc.? * Choose Yes No

Insured party 5

Name insured party

Date of birth

Sex * Choose Male Female

Do you have or have you had: serious illnesses/surgery, cancer, heart condition, diabetes, transplant, etc.? * Choose Yes No

Insured party 6

Name insured party

Date of birth

Sex * Choose Male Female

Do you have or have you had: serious illnesses/surgery, cancer, heart condition, diabetes, transplant, etc.? * Choose Yes No

General questions for the interested party

Current status

Are the insured covered by Spanish Social Security? * Choose Yes No

Are the insured covered by Social Security in another country? * Choose Yes No

What country?

How many months are you in Spain each year? *

How many months are you in Spain each year on holiday? *

Current insurance

Are you currently insured with another company? * Choose Yes No

If so, which one?

Since when

Next expiry date

Current premium amount

What do you find the main disadvantages of your current insurance?

Purpose future insurance

Do you consider it as an additional insurance in order to avoid the long waiting times of the social security or as the only insurence you wish to appeal to in the future

What is your maximum monthly budget for the whole familiy

Coverage required

Type of coverage * Choose Integral: only choice from doctors and clinics affiliated with DKV (cheapest option) Mundi: free choice in Spain and abroad (more expensive option)

Would you also like information on a funeral insurance? Recommended due to the difference in this field between Spain and other countries

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GrupoXandravk S.L., tratará sus datos personales para dar respuesta a las solicitudes planteadas a cerca de los seguros. En este formulario no es necesario darnos datos de salud, rogamos se abstengan de ello. Puede ejercer sus derechos de acceso, rectificación, supresión y portabilidad de sus datos, de limitación y oposición a su tratamiento, así como a no ser objeto de decisiones basadas únicamente en el tratamiento automatizado de sus datos, cuando procedan, en la dirección de correo electrónico info@grupoxandra.eu Le recomendamos que lea la política de privacidad antes de proporcionarnos sus datos personales.