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Online Application Form
Online Application Form
Application
1
General information
2
The main member
3
Date of inception
4
Persons to be covered
5
Method of payment
6
Direct debit mandate
7
End
COVER REQUIRED
*
GOLD Health Insurance
SILVER Health Insurance (Consultations and Visits Excluded)
HOSPITALISATION Insurance
TOP-UP Health Insurance
Level
*
CLASSIC with no medical questionnaire
COMFORT
LUXURY
If you are only taking out TOP-UP cover, please attach proof of your basic medical insurance scheme (copy Carte Vitale/attestation)
Drop files here or
Select files
Max. file size: 2 MB.
I already have compulsory insurance for medical expenses caused by accidents
(You will receive a 15% discount on your basic premium)
Please attach proof of your accident insurance (letter from your employer or copy of payslip)
Drop files here or
Select files
Max. file size: 2 MB.
Title
*
Mr
Mrs
Miss
Ms
Dr
NAME
*
First
Last
ADDRESS
*
Street Address
City
ZIP / Postal Code
Country
*
Austria - Autriche
Belgium – Belgique
Bulgaria - Bulgarie
Cyprus - Chypre
Czech Republic - République Tchèque
Denmark - Dannemark
Estonia - Estonie
Finland - Finlande
France - France
Germany - Allemagne
Greece - Grèce
Hungary - Hongrie
Iceland - Islande
Ireland - Irlande
Italy - Italie
Latvia - Lettonie
Liechtenstein - Liechtenstein
Lithuania - Littuanie
Luxembourg - Luxembourg
Malta - Malte
Netherlands - Hollande
Norway - Norvège
Poland - Pologne
Portugal – Portugal
Romania – Roumanie
Slovakia - Slovaquie
Slovenia - Slovénie
Spain - Espagne
Sweden – Suède
Switzerland - Suisse
United-Kingdom - Royaume Uni
Email
*
Telephone
*
Mobile
Fax
Occupation
*
Please attach proof if you are a student
Drop files here or
Select files
Max. file size: 2 MB.
For all levels of cover except SILVER, COMFORT and CLASSIC Top-Up, please tick here if you are left-handed
(for the personal accident cover)
Date of inception required
*
IMMEDIATE (the date of receipt of your completed application form at the earliest)
SPECIFY A DATE
DATE - the date of receipt of your completed application form at the earliest
Day
Month
Year
Waiting period
*
Yes
No
Please attach evidence of previous medical cover
Drop files here or
Select files
Max. file size: 2 MB.
If you reply NO, you confirm that all the persons to be covered had equivalent health cover up to three months or less before the date of membership to the AMARIZ SANTE plan (please attach a copy of your ‘Carte Vitale’ or of the ’attestation’ you received with this document, and/or a certificate of cancellation from your previous health insurer indicating the dates of cover and benefit levels). If no evidence of previous medical cover is attached to this application form, the waiting period will be applied (see Article 2 of the policy wording).
Person 1
NAME
*
First
Last
Date of birth
*
Day
Month
Year
Sex
*
Height
*
Weight
*
Blood pressure (COMPULSORY)
*
Systolic / Diastolic
Have you had any medical consultation/investigations/treatment in the last 6 months or is any planned?
*
Yes
No
If so, please provide full details:
*
Have you ever been hospitalised or had surgery?
*
Yes
No
Date and reason:
*
Do you need to be hospitalised or have surgery?
*
Yes
No
Date and reason:
*
Have you received or are you currently receiving regular medical treatment (medication, physiotherapy, psychotherapy, equipment)?
*
Yes
No
Please provide details
*
Do you suffer from a chronic or long-term illness?
*
Yes
No
Please provide details
*
Do you have any aftereffects from an accident, illness or disability?
*
Yes
No
Please provide details
*
Have you ever been or are you currently signed off work by a doctor for medical reasons?
*
Yes
No
Please provide details
*
Do you have any dentures, dental implants or orthodontic work planned within the next 12 months?
*
Yes
No
Please attach a quote
*
Drop files here or
Select files
Max. file size: 2 MB.
Do you suffer from any allergies?
*
Yes
No
If so, please provide details:
*
Do you smoke?
*
Yes
No
Are you pregnant?
*
Yes
No
Add a second person?
*
Yes
No
Person 2
NAME
*
First
Last
Date of birth
*
Day
Month
Year
Sex
*
Height
*
Weight
*
Blood pressure (COMPULSORY)
*
Systolic / Diastolic
Have you had any medical consultation/investigations/treatment in the last 6 months or is any planned?
*
Yes
No
If so, please provide full details:
*
Have you ever been hospitalised or had surgery?
*
Yes
No
Date and reason:
*
Do you need to be hospitalised or have surgery?
*
Yes
No
Date and reason:
*
Have you received or are you currently receiving regular medical treatment (medication, physiotherapy, psychotherapy, equipment)?
*
Yes
No
Please provide details
*
Do you suffer from a chronic or long-term illness?
*
Yes
No
Please provide details
*
Do you have any aftereffects from an accident, illness or disability?
*
Yes
No
Please provide details
*
Have you ever been or are you currently signed off work by a doctor for medical reasons?
*
Yes
No
Please provide details
*
Do you have any dentures, dental implants or orthodontic work planned within the next 12 months?
*
Yes
No
Please attach a quote
*
Max. file size: 2 MB.
Do you suffer from any allergies?
*
Yes
No
If so, please provide details:
*
Do you smoke?
*
Yes
No
Are you pregnant?
*
Yes
No
Add a third person?
*
Yes
No
Person 3
NAME
First
Last
Date of birth
*
Day
Month
Year
Sex
*
Height
*
Weight
*
Blood pressure (COMPULSORY)
*
Systolic / Diastolic
Have you had any medical consultation/investigations/treatment in the last 6 months or is any planned?
*
Yes
No
If so, please provide full details:
*
Have you ever been hospitalised or had surgery?
*
Yes
No
Date and reason:
*
Do you need to be hospitalised or have surgery?
*
Yes
No
Date and reason:
*
Have you received or are you currently receiving regular medical treatment (medication, physiotherapy, psychotherapy, equipment)?
*
Yes
No
Please provide details
*
Do you suffer from a chronic or long-term illness?
*
Yes
No
Please provide details
*
Do you have any aftereffects from an accident, illness or disability?
*
Yes
No
Please provide details
*
Have you ever been or are you currently signed off work by a doctor for medical reasons?
*
Yes
No
Please provide details
*
Do you have any dentures, dental implants or orthodontic work planned within the next 12 months?
*
Yes
No
Please attach a quote
*
Drop files here or
Select files
Max. file size: 2 MB.
Do you suffer from any allergies?
*
Yes
No
If so, please provide details:
*
Do you smoke?
*
Yes
No
Are you pregnant?
*
Yes
No
Add a fourth person?
*
Yes
No
Person 4
NAME
*
First
Last
Date of birth
*
Day
Month
Year
Sex
*
Height
*
Weight
*
Blood pressure (COMPULSORY)
*
Systolic / Diastolic
Have you had any medical consultation/investigations/treatment in the last 6 months or is any planned?
*
Yes
No
If so, please provide full details:
*
Have you ever been hospitalised or had surgery?
*
Yes
No
Date and reason:
*
Do you need to be hospitalised or have surgery?
*
Yes
No
Date and reason:
*
Have you received or are you currently receiving regular medical treatment (medication, physiotherapy, psychotherapy, equipment)?
*
Yes
No
Please provide details
*
Do you suffer from a chronic or long-term illness?
*
Yes
No
Please provide details
*
Do you have any aftereffects from an accident, illness or disability?
*
Yes
No
Please provide details
*
Have you ever been or are you currently signed off work by a doctor for medical reasons?
*
Yes
No
Please provide details
*
Do you have any dentures, dental implants or orthodontic work planned within the next 12 months?
*
Yes
No
Please attach a quote
*
Drop files here or
Select files
Max. file size: 2 MB.
Do you suffer from any allergies?
*
Yes
No
If so, please provide details:
*
Do you smoke?
*
Yes
No
Are you pregnant?
*
Yes
No
Add a fifth person?
*
Yes
No
Person 5
NAME
*
First
Last
Date of birth
*
Day
Month
Year
Sex
*
Height
*
Weight
*
Blood pressure (COMPULSORY)
*
Systolic / Diastolic
Have you had any medical consultation/investigations/treatment in the last 6 months or is any planned?
*
Yes
No
If so, please provide full details:
*
Have you ever been hospitalised or had surgery?
*
Yes
No
Date and reason:
*
Do you need to be hospitalised or have surgery?
*
Yes
No
Date and reason:
*
Have you received or are you currently receiving regular medical treatment (medication, physiotherapy, psychotherapy, equipment)?
*
Yes
No
Please provide details
*
Do you suffer from a chronic or long-term illness?
*
Yes
No
Please provide details
*
Do you have any aftereffects from an accident, illness or disability?
*
Yes
No
Please provide details
*
Have you ever been or are you currently signed off work by a doctor for medical reasons?
*
Yes
No
Please provide details
*
Do you have any dentures, dental implants or orthodontic work planned within the next 12 months?
*
Yes
No
Please attach a quote
*
Drop files here or
Select files
Max. file size: 2 MB.
Do you suffer from any allergies?
*
Yes
No
If so, please provide details:
*
Do you smoke?
*
Yes
No
Are you pregnant?
*
Yes
No
Add a sixth person?
*
Yes
No
Person 6
NAME
*
First
Last
Date of birth
*
Day
Month
Year
Sex
*
Height
*
Weight
*
Blood pressure (COMPULSORY)
*
Systolic / Diastolic
Have you had any medical consultation/investigations/treatment in the last 6 months or is any planned?
*
Yes
No
If so, please provide full details:
*
Have you ever been hospitalised or had surgery?
*
Yes
No
Date and reason:
*
Do you need to be hospitalised or have surgery?
*
Yes
No
Date and reason
*
Have you received or are you currently receiving regular medical treatment (medication, physiotherapy, psychotherapy, equipment)?
*
Yes
No
Please provide details
*
Do you suffer from a chronic or long-term illness?
*
Yes
No
Please provide details
*
Do you have any aftereffects from an accident, illness or disability?
*
Yes
No
Please provide details
*
Have you ever been or are you currently signed off work by a doctor for medical reasons?
*
Yes
No
Please provide details
*
Do you have any dentures, dental implants or orthodontic work planned within the next 12 months?
*
Yes
No
Please attach a quote
*
Drop files here or
Select files
Max. file size: 2 MB.
Do you suffer from any allergies?
*
Yes
No
If so, please provide details:
*
Do you smoke?
*
Yes
No
Are you pregnant?
*
Yes
No
Premiums are payable in advance:
*
Monthly
Quarterly
Six-monthly
Annually (5% discount for annual payment)
Method of payment:
*
By direct debit on the 8th of the month
By bank transfer
By cheque
Creditor
AMARIZ LIMITED
Identifier of the Creditor
FR02ZZZ476535
*
By signing this mandate form, you authorise (A) the Creditor to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from the Creditor. As parts of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that you can obtain from your bank.
Account Holder
NAME
*
First
Last
ADDRESS
*
Street Address
City
ZIP / Postal Code
Country
*
Austria - Autriche
Belgium – Belgique
Bulgaria - Bulgarie
Cyprus - Chypre
Czech Republic - République Tchèque
Denmark - Dannemark
Estonia - Estonie
Finland - Finlande
France - France
Germany - Allemagne
Greece - Grèce
Hungary - Hongrie
Iceland - Islande
Ireland - Irlande
Italy - Italie
Latvia - Lettonie
Liechtenstein - Liechtenstein
Lithuania - Littuanie
Luxembourg - Luxembourg
Malta - Malte
Netherlands - Hollande
Norway - Norvège
Poland - Pologne
Portugal – Portugal
Romania – Roumanie
Slovakia - Slovaquie
Slovenia - Slovénie
Spain - Espagne
Sweden – Suède
Switzerland - Suisse
United-Kingdom - Royaume Uni
Account number to be debited
*
IBAN + BIC
Please attach a RIB (Relevé d'Identité Bancaire) for payment of premiums
Drop files here or
Select files
Max. file size: 2 MB.
NOTES: Direct debits are carried out on the 8th day of the month. In the event of an unpaid direct debit, costs (bank charges and related charges) will be payable by the Member.
I would like my claims payments to be made by bank transfer into this account
I would like my claims payments to be made into a different account.
NOTES: Direct debits are carried out on the 8th day of the month. In the event of an unpaid direct debit, costs (bank charges and related charges) will be payable by the Member.
Please attach a RIB (Relevé d'Identité Bancaire) for payment of claims
Drop files here or
Select files
Max. file size: 2 MB.
ADRESSE DE LA BANQUE
*
Street Address
City
ZIP / Postal Code
Where did you hear about our company?
*
Google advert
Google search
Other internet search
Friend / Colleague
Client
Other (please stipulate)
Please stipulate
*
YOUR PERSONAL INFORMATION: We need your consent to use the sensitive details about you in this application form in connection with your insurance cover. You do not have to give your consent and you may withdraw your consent at any time. However, if you do not give your consent, or you withdraw your consent, this may affect our ability to provide you with insurance cover or to handle your claims. I CONSENT TO THE USE OF DATA AND INFORMATION ABOUT MY HEALTH IN CONNECTION WITH MY INSURANCE COVER.
*
Yes
No
YOUR PERSONAL INFORMATION: We need your consent to use sensitive details about you relating to your health in connection with claims. You do not have to give your consent and you may withdraw your consent at any time. However, if you do not give your consent, or you withdraw your consent, this may prevent us from handling or otherwise affect our ability to handle your claims. I CONSENT TO THE USE OF DATA AND INFORMATION ABOUT MY HEALTH IN CONNECTION WITH MY CLAIMS UNDER THIS POLICY.
*
Yes
No
OTHER PEOPLE’S DETAILS YOU PROVIDE TO US: Where you provide us with details about other people to be insured, we also need their consent to use the sensitive details about in this application form them in connection with your insurance cover. You should obtain their consent before providing these details to us. I HAVE OBTAINED THE CONSENT OF EACH OTHER PERSON LISTED IN THIS APPLICATION FORM TO THE USE OF DATA AND INFORMATION ABOUT THEIR HEALTH IN CONNECTION WITH MY INSURANCE COVER.
*
Yes
No
OTHER PEOPLE’S DETAILS YOU PROVIDE TO US: Where you provide us with details about other people on your policy, we also need their consent to use their sensitive details relating to their health in connection with claims. You should obtain their consent before providing these details to us. I HAVE OBTAINED THE CONSENT OF EACH OTHER PERSON LISTED ON THIS APPLICATION FORM TO THE USE OF DATA AND INFORMATION ABOUT THEIR HEALTH IN CONNECTION WITH CLAIMS UNDER THIS POLICY.
*
Yes
No
From time to time we would like to contact you by email with details of the products and services we provide. Please confirm your consent below:
*
Yes
No
We will not share your email address with any third parties and you can withdraw your consent at any time in accordance with our Privacy Notice.
See our Privacy Notice
By clicking "Submit", I acknowledge receipt of
the Privacy Policy
.