Sanitas Application Form

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Oficina Sant Gervasi Sanitas Oficina Sant Gervasi

Agente exclusivo de Sanitas

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Step 1 of 11

Sanitas Application Form

Effective date

Month*

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Sin nombre

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Fecha

DD slash MM slash YYYY

Policyholder details

First Name*

Last Name*

Sex*

Date of birth*

DD slash MM slash YYYY

Doc type*

Document n.*

Nationality*

Contact details

Phone number*

Email*

Address

You can skip this section if you do not yet have a domicile in Spain.

Street type

Address 1

Address 2

Postcode

City

N. of insured

To be completed by insured n. 1

The policyholder's details are the same as those of the first insured.

First Name*

Last Name*

Sex*

Date of birth*

DD slash MM slash YYYY

Doc type*

Document n.*

Nationality*

Phone number*

Email*

Health questionnaire insured n. 1

Weight*

Height*

1. Do you have or have you had a disease or accident in the last 5 years that required medical treatment?*

Yes

If yes, please give details*

2. Have you been admitted to hospital or had an operation or do you have one scheduled shortly?*

Yes

If yes, please give details*

3. Are you currently under medical treatment or monitoring?*

Yes

If yes, please give details*

4. Have you recently had any medical tests or have you any scheduled?*

Yes

If yes, please give details*

5. Do you have any undiagnosed symptoms or pain that appears constantly or repeatedly?*

Yes

If yes, please give details*

To be completed by insured n. 2

First Name*

Last Name*

Sex*

Date of birth*

DD slash MM slash YYYY

Doc type*

Document n.*

Nationality*

Health questionnaire insured n. 2

Weight*

Height*

1. Do you have or have you had a disease or accident in the last 5 years that required medical treatment?*

Yes

If yes, please give details*

2. Have you been admitted to hospital or had an operation or do you have one scheduled shortly?*

Yes

If yes, please give details*

3. Are you currently under medical treatment or monitoring?*

Yes

If yes, please give details*

4. Have you recently had any medical tests or have you any scheduled?*

Yes

If yes, please give details*

5. Do you have any undiagnosed symptoms or pain that appears constantly or repeatedly?*

Yes

If yes, please give details*

To be completed by insured n. 3

First Name*

Last Name*

Sex*

Date of birth*

DD slash MM slash YYYY

Doc type*

Document n.*

Nationality*

Health questionnaire insured n. 3

Weight*

Height*

1. Do you have or have you had a disease or accident in the last 5 years that required medical treatment?*

Yes

If yes, please give details*

2. Have you been admitted to hospital or had an operation or do you have one scheduled shortly?*

Yes

If yes, please give details*

3. Are you currently under medical treatment or monitoring?*

Yes

If yes, please give details*

4. Have you recently had any medical tests or have you any scheduled?*

Yes

If yes, please give details*

5. Do you have any undiagnosed symptoms or pain that appears constantly or repeatedly?*

Yes

If yes, please give details*

To be completed by insured n. 4

First Name*

Last Name*

Sex*

Date of birth*

DD slash MM slash YYYY

Doc type*

Document n.*

Nationality*

Health questionnaire insured n. 4

Weight*

Height*

1. Do you have or have you had a disease or accident in the last 5 years that required medical treatment?*

Yes

If yes, please give details*

2. Have you been admitted to hospital or had an operation or do you have one scheduled shortly?*

Yes

If yes, please give details*

3. Are you currently under medical treatment or monitoring?*

Yes

If yes, please give details*

4. Have you recently had any medical tests or have you any scheduled?*

Yes

If yes, please give details*

5. Do you have any undiagnosed symptoms or pain that appears constantly or repeatedly?*

Yes

If yes, please give details*

To be completed by insured n. 5

First Name*

Last Name*

Sex*

Date of birth*

DD slash MM slash YYYY

Doc type*

Document n.*

Nationality*

Health questionnaire insured n. 5

Weight*

Height*

1. Do you have or have you had a disease or accident in the last 5 years that required medical treatment?*

Yes

If yes, please give details*

2. Have you been admitted to hospital or had an operation or do you have one scheduled shortly?*

Yes

If yes, please give details*

3. Are you currently under medical treatment or monitoring?*

Yes

If yes, please give details*

4. Have you recently had any medical tests or have you any scheduled?*

Yes

If yes, please give details*

5. Do you have any undiagnosed symptoms or pain that appears constantly or repeatedly?*

Yes

If yes, please give details*

To be completed by insured n. 6

First Name*

Last Name*

Sex*

Date of birth*

DD slash MM slash YYYY

Doc type*

Document n.*

Nationality*

Health questionnaire insured n. 6

Weight*

Height*

1. Do you have or have you had a disease or accident in the last 5 years that required medical treatment?*

Yes

If yes, please give details*

2. Have you been admitted to hospital or had an operation or do you have one scheduled shortly?*

Yes

If yes, please give details*

3. Are you currently under medical treatment or monitoring?*

Yes

If yes, please give details*

4. Have you recently had any medical tests or have you any scheduled?*

Yes

If yes, please give details*

5. Do you have any undiagnosed symptoms or pain that appears constantly or repeatedly?*

Yes

If yes, please give details*

To be completed by insured n. 7

First Name*

Last Name*

Sex*

Date of birth*

DD slash MM slash YYYY

Doc type*

Document n.*

Nationality*

Health questionnaire insured n. 7

Weight*

Height*

1. Do you have or have you had a disease or accident in the last 5 years that required medical treatment?*

Yes

If yes, please give details*

2. Have you been admitted to hospital or had an operation or do you have one scheduled shortly?*

Yes

If yes, please give details*

3. Are you currently under medical treatment or monitoring?*

Yes

If yes, please give details*

4. Have you recently had any medical tests or have you any scheduled?*

Yes

If yes, please give details*

5. Do you have any undiagnosed symptoms or pain that appears constantly or repeatedly?*

Yes

If yes, please give details*

To be completed by insured n. 8

First Name*

Last Name*

Sex*

Date of birth*

DD slash MM slash YYYY

Doc type*

Document n.*

Nationality*

Health questionnaire insured n. 8

Weight*

Height*

1. Do you have or have you had a disease or accident in the last 5 years that required medical treatment?*

Yes

If yes, please give details*

2. Have you been admitted to hospital or had an operation or do you have one scheduled shortly?*

Yes

If yes, please give details*

3. Are you currently under medical treatment or monitoring?*

Yes

If yes, please give details*

4. Have you recently had any medical tests or have you any scheduled?*

Yes

If yes, please give details*

5. Do you have any undiagnosed symptoms or pain that appears constantly or repeatedly?*

Yes

If yes, please give details*

To be completed by insured n. 9

First Name*

Last Name*

Sex*

Date of birth*

DD slash MM slash YYYY

Doc type*

Document n.*

Nationality*

Health questionnaire insured n. 9

Weight*

Height*

1. Do you have or have you had a disease or accident in the last 5 years that required medical treatment?*

Yes

If yes, please give details*

2. Have you been admitted to hospital or had an operation or do you have one scheduled shortly?*

Yes

If yes, please give details*

3. Are you currently under medical treatment or monitoring?*

Yes

If yes, please give details*

4. Have you recently had any medical tests or have you any scheduled?*

Yes

If yes, please give details*

5. Do you have any undiagnosed symptoms or pain that appears constantly or repeatedly?*

Yes

If yes, please give details*

Payment details and documentation

Method of payment*

We will send you the payment instructions by email. This option requires a single payment for the full policy period (annual or total duration).

Note: For policies with a duration of less than 12 months, one-time payment is required. Monthly or recurring payments are not available for short-term coverage.

Payment frequency*

IBAN*

Only SEPA bank accounts (Europe)

Card number*

Month*

Year*

Passports*

Please upload the passports for all the insured here

Drop files here or

Max. file size: 100 MB.

Nombre producto

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Edat

Nombre producto

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Número

Consent*

I consent to the collection and secure processing of my personal, health, and payment information for the purpose of applying for Sanitas health insurance. I have read and accept the Privacy Policy.

Note: Your payment will only be processed after the digital signature of the policy has been completed.

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token

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Product