Insurance Application
MA RK IN TH E CA SE OF TRA N SFER Incorporation
Application number Policy number
Modification
Transfer
Sub-group number
Certificate number
Delegation
Effective date
Expiry
Remittance of documentation
Campaign
Mediator Code 1 ____________________________________________________________
Customer
Mediator
Delegation
Zone
KAM
Group
Mediator Code 2 ____________________________________________________________
Transfer Data - (TO BE FILLED IN ONLY IN CASES OF TRANSFER) (1) No. of Policy of Origin (2)
Return of premium
Certificate No. (2)
Cancellation of policy in full
Cancellation of the insured transferred (REMAINDER OF THE INSURED MAINTAINED)
Policyholder Data Surname and First Name _____________________________________________________________________________________ NIF/NIE ______________________________________
Address: Type of Roadway (4)
Street name ____________________________________________________________________ Street number _________ Floor ________
Postal Code ____________________ Town or City ______________________________________________________________________________________________________________
Profession (4)
Date of birth_________________________________________________ Marital Status (4)
Gender
Male
Female
Telephone no._____________________________ Mobile phone _____________________________ E-mail address _______________________________________________________ Bank Account Language of documentation (4) Form of payment (4) Number Additional Policyholder data (To be filled in ONLY IF POLICYHOLDER IS THE INSURED) (IF THIS SECTION IS FILLED IN IT IS NOT NECESSARY TO FILL IN THE DATA OF POLICYHOLDER AS THE INSURED)
Have you previously been a customer of the Company?
No. of Policy of Origin
Yes
No
Do you request Exceptions from Exclusions? (5)
Yes
No
Participating Providers
Certificate no.
Insured Data 1)
Surname and First Name _________________________________________________________________________________ NIF/NIE _______________________________________ Address __________________________________________________________________ Date of birth____________________________________ Profession (4)
Postal Code ________________ Town or City __________________________________ Gender
Male
Female Relationship (4)
Medical Team
Telephone number ___________________________ Mobile phone ___________________________ E-mail address____________________________________________________ Have you previously been a customer of the Company?
ONLY IN THE CASE OF TRANSFER:
2)
Yes
No
Are you requesting exemption from the claims waiting period? (5)
No. of Policy of Origin (3)
Yes
No
Certificate no. (3)
Surname and First Name _________________________________________________________________________________ NIF/NIE _______________________________________ Address __________________________________________________________________ Date of birth____________________________________ Profession (4)
Postal Code ________________ Town or City __________________________________ Gender
Male
Female Relationship (4)
Medical Team
Telephone number ___________________________ Mobile phone ___________________________ E-mail address____________________________________________________ Have you previously been a customer of the Company?
ONLY IN THE CASE OF TRANSFER:
3)
Yes
No
No. of Policy of Origin
Are you requesting exemption from the claims waiting period? (5)
(3)
Certificate no.
Yes
No
(3)
Surname and First Name _________________________________________________________________________________ NIF/NIE _______________________________________ Address __________________________________________________________________ Date of birth____________________________________ Profession (4)
Postal Code ________________ Town or City __________________________________ Gender
Male
Female Relationship (4)
Medical Team
Telephone number ___________________________ Mobile phone ___________________________ E-mail address____________________________________________________ Have you previously been a customer of the Company?
ONLY IN THE CASE OF TRANSFER:
4)
Yes
No
No. of Policy of Origin
Are you requesting exemption from the claims waiting period? (5)
(3)
Certificate no.
Yes
No
(3)
Surname and First Name _________________________________________________________________________________ NIF/NIE _______________________________________ Address __________________________________________________________________ Date of birth____________________________________ Profession (4)
Postal Code ________________ Town or City __________________________________ Gender
Male
Female Relationship (4)
Medical Team
Telephone number ___________________________ Mobile phone ___________________________ E-mail address____________________________________________________ Have you previously been a customer of the Company?
ONLY IN THE CASE OF TRANSFER:
Yes
No
Are you requesting exemption from the claims waiting period? (5)
No. of Policy of Origin (3)
Yes
No
Certificate no. (3)
PRODUCT
OBSERVATIONS
Additional information per insured
S.OS.F.01 I/05
Application Decision:
Insured 1
ACCEPTED
REJECTED
Insured 2
EXCLUSIONS
Insured 3
Insured 4
(1), (2), (3), (4) and (5) See instructions on reverse side.
In accordance with that stated in the section “'TREATMENT AND TRANSFER OF PERSONAL DETAILS” which appears on the reverse side of this insurance request, please mark the corresponding box/es if you do not wish to be sent information and/or you do not want your details to be transferred as stated. I do not accept the use of my personal details for promotional purposes. I do not want my details to be given to third parties.
Date___________________________ Signature _________________________________
SegurCaixa Adeslas, S.A. de Seguros y Reaseguros - Juan Gris 20-26, 08014 Barcelona (Spain). Registered in the Commercial Registy of Barcelona, book 20481, sheet 130, page B6492. VAT No.:A28011864
Copy for the Company
Policyholder
TREATMENT AND TRANSFER OF PERSONAL DETAILS In the policy’s General Conditions there is a section in which the policy holder/insured party is informed that his/her personal information must be processed in order for the policy to be set up. This insurance application sets out those voluntary conditions which the policy holder/insured party can decide not to agree to, expressing their wishes to this effect on the insurance application form. Should they do so, this will not have any adverse effect on the policy being successfully set up. Notwithstanding the necessary treatment of your personal details and those of the insured parties included on this request for risk assessment and, if applicable, contracting and the subsequent management of the requested health insurance, please be advised that, with regards to your personal contact details, (name, surname, date of birrh, address, telephone numbers and email address), our Entity intends to use them for the following purposes: (i) for promotional purposes an to offer you products and services marketed by our entity or by other collaborating entities which may interest you, even in the event that the policy is not signed or is terminated for any reason; (ii) for the application of statistical techniques in order to draw up profiles and segmentation of data so that the commercial communication referred to in the previous and segmentation of data so that the commercial communication referred to in the previous point is carried out with previously selected criteria; (iii) to provide them to the financial entity Caixabank, S.A., with Fiscal Identification Number A-08663619 and address in Barcelona (08028), Avenida Diagonal, 621 and to the companies, entities or foundations of the Grupo Caja de Ahorros y Pensiones de Barcelona, whose activities form part of the insurance, banking, investment services, share holdings, venture capital, property, road, sale and distribution of goods and services, leisure, consultancy services and charity-social sectors, in order to provide you with commercial information regarding their products and services. Consent granted by yourself to be sent commercial communication regarding products and services by the insurance company and the aforementioned concessionary companies will also comprise their remittance by email or any other means of equivalent electronic communication. If you do not accept this use and/or communication of your personal details you may indicate this by marking the boxes included for this purpose on the front of this document, without this refusal hindering the processing of this insurance request and, if applicable, contracting of the policy. In any case, you may subsequently exercise at any time, in accordance with the terms and conditions provided for in the applicable legislation, your rights to opposition, access, rectification and cancellation with regards to our company or any of the aforementioned concessionary entities, by written and signed request, with proof of identity, sent to the business address of any of these entities.
Information of interest to the customer: In accordance with what is set out in the currently valid Arrangement and Supervision of Private Insurance Law and its development Regulations, the applicant is informed that the insurance undertaking is SegurCaixa Adeslas, S.A. de Seguros y Reaseguros whose fiscal identification number is: A-28011864, and that its registered office is at: Calle Juan Gris, 20-26, Barcelona (08014), as appears in the Chamber of Commerce tome 20481, folio 130, page B-6492, and that the insurance contract which is being requested is subject to Spanish legislation. Furthermore, the applicant is informed that, without prejudice to the possibility of resorting to legal proceedings, the policy holder, the insured party, the beneficiary, injured parties or any of their rightsholders, will be able to file complaints and/or claims against actions on the part of the insurer which he/she considers injurious or which infringe on his/her legally recognised rights or interests as set out in the insurance contract, with the following bodies: 1 The Customer Service Centre, in accordance with the procedures set out in its Regulations. 2 The Insurance Ombudsman, in accordance with the procedures set out in the ombudsman’s Regulations. 3 The Commissioner for the Protection of Insured Persons and of Contributors to Pension Plans (functions taken on by the Customer Service Department of the Executive Board for Insurance and Pensions Funds). For this body to accept and process complaints it is necessary for the claimant to demonstrate that the complaint has been correctly presented to the Customer Service Centre or the Insurance Ombudsman and has been rejected, turned down or that more than two months have passed since it was presented without a settlement being reached.
INSTRUCTION SHEET (1) Transfer: This occurs when an SegurCaixa Adeslas client requests a change in product involving the cancellation of the current contract and the signing of a new policy contract. This change must be from one product to another pr oduct in the same family (fr om health insurance to health insurance, fr om dental to dental, fr om accident to accident, etc.). Furthermor e, the client must have no outstanding payments for the current policy and insurance must be continuous (that is, the cancellation date of the current policy must coincide with the starting date of the new transfer policy, so that there is no time period without insurance). (2) In the case of transfer, when all the persons insured by the new policy belong originally to the same contract, the original policy will be included in the “Data transfer” section, in the “Original Policy Number” box in the Application Form (pure transfer). (3) In the case of transfer, if the persons insured by the new policy belong originally to different policies, the original policy will be included in the box corresponding to the information of each person insured (section “Insured Person Information”, sub section “Only Transfers”). (4) Codes to be used (see Tables included). (5) Claims Waiting Period Exemption: If the policyholder and/or insured request exemption from the claims waiting period, it is necessary to attach to the application the receipts accrediting payment of the previous policy premium, together with the specific and/or general terms and conditions of the product which they had previously contracted.
Language of documentation 1: Spanish 2: Catalan
Type of Roadway AG: AL: AP: AV: BC: BD: BL: BO: CH: CJ: CL: CM: CO: CR: CS: CT: DS: ED: GL: GR: LG: MC: PD: PG: PJ: PL: PQ: PR: PS: PZ: RB: RD: SD: SN: TR: TT: UR:
Housing group Grove Apartments Avenue Bluff Descending slope Unit Quarter Chalet Lane Street Road Residential settlement Highway House Hill Disseminated habitat Building Square Group Place Market Rural division Industrial park Passage Small square Park Prolongation Promenade Plaza Boulevard Circle Rising slope Path Crossing Torrent Housing Development
Marital Status S: C: E: D: V: O:
Single Married/Partnered Separated Divorced Widowed Other
Form of Payment A: M: B: S: T:
Annually Monthly Bi-monthly Six- monthly Quarterly
Relationship CO: HI: NI: PA: AB:
Spouse Son/daughter Grandchild Father or mother Grandparent, Great-grandparent HE: Brother/Sister, cousin OT: Other
Code
Profession
099 900 939 968 913 914 969 915 901 940 941 970 990 971 916 942 943 944 945 917 902 918 972 946 903
Undefined Clerical worker Farmer Housewife Beekeeper Artist in workshop Sawyer Poultry producer Ground hostess or trade fair hostess Airline hostess Garbage collector Fireman, Policeman, Civil Guard Opera Singer Quarryman not dealing with explosives Postman (delivery) Postman (delivery by vehicle) Bill Collector Salesman working outside of work center Vehicle or machinery driver Concierge (doing maintenance work) Concierge (with no maintenance work) Decorator Professional Athlete Executive traveling frequently Commercial Not working outside work and no loading/ unloading/Shop assistant Beauty salon employee/Esthetician Employee engaging in loading/ unloading work without machinery Chemical industry employee School employee (except teachers) Docker Stevedore Student Flower grower-Tree grower Photographer Studio photographer Civil servant Caster Cattle rancher Armed Security Guard Tour guide Herbalist including herb collection Horticulturist Hotel and Restaurant employee / waiter Transformation industry using machinery Recycling industry
904 919 947 920 921 973 974 922 923 905 975 976 948 977 949 924 925 926 950 951
Code 952 953 927 978 954 928 979 980 929 906 955 981 982 967 930 907 931 932 956 933 934 983 957 984 985 935 908 958 909 959 986 987 960 910 936 937 911 988 961 989 962 963 912 964 965 938 966
Profession Industrial/domestic install. on building exteriors Install. / repair heat, antennas, elevators Industrial/domestic install. in building interiors Gardener (including tree pruning) Gardener (with no tree pruning) Jeweler (manufacture and repair) Retiree / Pensioner Lumberjack Cleaning building interiors Radio /TV announcer in studio Automobile or machinery mechanic or plate worker Courier Miner Not self-employed Office messenger (doing maintenance work) Office messenger (no maintenance work) Bread baker Pastry baker Journalist (national territory) Healthcare personnel in hospital, clinic, ambulatory clinic Healthcare personnel in laboratory or workshop Offshore fisherman Coastal fisherman, navigator with sea days of less than 24 hours Pilot Scaffolding painter Building doorman (doing maintenance work) Building doorman (with no maintenance work) Professional traveling frequently (more than once a week) Professional working in an office Professional specializing in food industry/ Fisherman Professional (theatre, films, TV, music) Sport Activities teacher. Dance Driving school teacher Teacher (pre-school, elementary, secondary) Teacher professional school University professor-experimental sciences University professor- humanities Member of a religious order / Priests Graphic reporter (national territory) Welder (ships and works) Taxi driver University degree holder working outside of offices/shops University degree holder working in offices/shops Construction work on outside of buildings Loading and unloading work using machinery Construction work in building interiors Unarmed security guard