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HEALTH INSURANCE CREATE YOUR PACKAGE

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HEALTH INSURANCE CREATE YOUR PACKAGE

This application must be filled out and signed by every applicant. If the applicant is younger than 18 years old this form must be signed by a parent or guardian. A photo should be atached to this form.

Note: This offer will be valid for 15 days upon filling of the questionnaire. SIGAL UNIQA makes the quotation if the no contract is signed during this period, the application must be re-submitted and a new quotation should be made.

C. MEDICAL QUESTIONNAIRE

Are you in good health?*

Yes

Have you been admitted into a medical center for surgery? If yes, specify*

Yes

What surgery did you perform?*

Have you ever had a blood transfusion? If yes, why and when was it done?*

Yes

For what reason and when?*

In the last 12 months have you had any diagnostic tests/preventive tests?*

Yes

Do you currently need any medication or treatment or consulting a physician, doctor, physiotherapist?*

Yes

Specify for what disease or health condition you are pursuing?*

Do you have a clinic or hospital which you prefer among others?*

Yes

Hospitals / Private Clinics*

Do you use alcohol? If yes what do you drink and how frequently?*

Yes

Drinks you consume and how many times a week?*

Do you smoke, or have you ever smoked? If yes, how many cigarettes per day?*

Yes

How many cigarettes a day?*

Do you plan to travel? If frequently how long do you use to stay outside Albania*

Yes

How long do you stay outside Albania?*

Have you ever been or are you actually part of a voluntary insurance plan in Albania or abroad? If yes specify*

Yes

Period and name of insurance company*

Do you have other insurance contract with SIGAL UNIQA Group Austria? If yes, specify*

Yes

Period and type of insurance policy*

Do you use optical eye glasses and frames/contact lenses?*

Yes

Do you practice sport or frequent the gym in your leisure time? Specify in the section above*

Yes

How many times a week?*

Do you have relative / friends which have a private health insurance contract with SIGAL UNIQA Group AUSTRIA. Specify.*

Yes

Friends / Family*

For children of age 0-15 years old, please confirm if your request coverage for state program vaccines? If yes, please communicate with SIGAL UNIQA Health Underwriting department for the additional premium quotation

Yes

Do you practice sports, amateur or as a profession. If yes, please specify*

Yes

What kind of sport do you practice?*

Body measures:

Height *

Weight*

Blood pressure (tension):*

Min / Max

Did you suffer any of the following conditions/illnesses, if yes write the diagnostification year and treatment prescribed

Allergy

Skin problems

Rehumatism illness

Stomach liver illnesses

Blood illnesses

Kidney illnesses

Diabetes

Epilepsy

Hipertension

Heart illnesses

Tumors or other cancrous conditions

Breathing disorders

None of them

Year of diagnosis

Treatment period

Results

For any other additional information regarding the above mentioned questions please provide the necessary details in the above section by enclosing to this questionnaire the last documents of your medical performed examinations.

Attach ID Card Photo and medical records if you have

Max file size: 20.00 MB. | Allowed file types: gif,jpeg,png,jpg,pdf,docx,doc,tiff,HEIF,HEIC,jfif | Min number of file: 1

Upload ID Card or Passport Photo and Documents

I declare that I am fully aware that SIGAL will not pay/reimburse any expenses for the treatment of medical problems or bodily injuries that have happened before the beginning of the insurance coverage; I certify that I have truthfully answered the questions in the above sections, and that I am aware that this application is a part of the insurance policy and that the provision of false or incomplete information can cause the immediate dissolution of the contract and the non-payment of any contract benefits insurance I authorize every physician, hospital or private or public medical institution that I have consulted or that I will consult after the undersigning of this questionnaire, as well as every medical institution that possess medical information about me, with whom SIGAL may contact, even after the insurance event, to give information, report or respective document.. Also, I give my consent and authorize SIGAL UNIQA Group Austria to process the information on personal and sensitive data for purpose of insurance and reinsurance and give information about me to other institutions for technical statistical, insurance and reinsurance reasons. I give my consent for the international transfer of my personal and sensitive data for insurance and reinsurance purpose. In any case the processing of my personal data should be based on honest, fair and legal processing.

Your form has been successfully submitted

Thank you %NAME% that you filled out the health insurance form.

We have also attached a copy of your data to your email.

SIGAL UNIQA GROUP AUSTRIA

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HEALTH INSURANCE CREATE YOUR PACKAGE

HEALTH INSURANCE CREATE YOUR PACKAGE

This application must be filled out and signed by every applicant. If the applicant is younger than 18 years old this form must be signed by a parent or guardian. A photo should be atached to this form.

Note: This offer will be valid for 15 days upon filling of the questionnaire. SIGAL UNIQA makes the quotation if the no contract is signed during this period, the application must be re-submitted and a new quotation should be made.

C. MEDICAL QUESTIONNAIRE

Body measures:

Attach ID Card Photo and medical records if you have

Your form has been successfully submitted

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Individuals

Business

Contacts

Headquarters

Përshëndetje,

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HEALTH INSURANCE CREATE YOUR PACKAGE

HEALTH INSURANCE CREATE YOUR PACKAGE

This application must be filled out and signed by every applicant. If the applicant is younger than 18 years old this form must be signed by a parent or guardian. A photo should be atached to this form.

Note: This offer will be valid for 15 days upon filling of the questionnaire. SIGAL UNIQA makes the quotation if the no contract is signed during this period, the application must be re-submitted and a new quotation should be made.

C. MEDICAL QUESTIONNAIRE

Body measures:

Attach ID Card Photo and medical records if you have

Your form has been successfully submitted

Useful links

Services

Individuals

Business

Contacts

Headquarters

Përshëndetje,