Students Application Form

Sanitas International Students

Effective date

Month*

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Sin nombre

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

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

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Edat

Doc type*

Document n.*

Nationality*

Phone number*

Email*

Course's information

School/Univeristy province*

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*

Payment details and documentation

Method of payment*

Note: After submitting the form, we will contact you by email to explain how to make the payment by bank transfer. The payment covers the entire insurance period (maximum 1 year).

IBAN*

Only European bank accounts (SEPA)

Card number*

Month*

Year*

DNI/Passport/NIE*

Max. file size: 100 MB.

School/university admission letter*

Max. file size: 100 MB.

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Date

DD slash MM slash YYYY

Product Name

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Number

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

+34 934 19 27 84

Sanitas International Students

To be completed by insured n. 1

Course's information

Health questionnaire insured n. 1

Payment details and documentation