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Online Application Form Bronze
Online Application Form Bronze
Application - Bronze
1
The main member
2
Date of inception
3
Persons to be covered
4
Method of payment
5
Direct debit mandate
6
End
Title
*
Mr
Mrs
Miss
Ms
Dr
NAME
*
First
Last
ADDRESS
*
Street Address
City
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
*
Telephone
*
Mobile
Fax
Occupation
*
Length of cover required
*
1 MONTH
2 MONTHS
3 MONTHS
4 MONTHS
5 MONTHS
6 MONTHS
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
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 suffer from any allergies?
*
Yes
No
If so, please provide details:
*
Do you smoke?
*
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 suffer from any allergies?
*
Yes
No
If so, please provide details:
*
Do you smoke?
*
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 suffer from any allergies?
*
Yes
No
If so, please provide details:
*
Do you smoke?
*
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 suffer from any allergies?
*
Yes
No
If so, please provide details:
*
Do you smoke?
*
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 suffer from any allergies?
*
Yes
No
If so, please provide details:
*
Do you smoke?
*
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 suffer from any allergies?
*
Yes
No
If so, please provide details:
*
Do you smoke?
*
Yes
No
Premiums are payable in advance:
*
Monthly
Quarterly
Six-monthly
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.
By clicking "Submit", I acknowledge receipt of
the Privacy Policy
.