INDIVIDUAL HEALTH INSURANCE APPLICATION COMPANY

INDIVIDUAL HEALTH INSURANCE APPLICATION

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.

A. INSURANCE COVERAGE DETAILS

Given and Family names*

Given and Family names

Date of Birth*

Date of Birth ×

ID Number*

ID Number

Residence*

Residence

E-mail*

E-mail

Civil status (Family members.)*

Civil status (Family members.)

Profession / Employer*

Profession / Employer

Contact number*

Contact number

B. INFORMATION ABOUT HEALTH INSURANCE COVERAGE:

COMPANY*

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

No

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

Yes

No

What surgery did you perform?*

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

Yes

No

For what reason and when?*

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

Yes

No

Enter the name of the medical facility where you performed medical checks*

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

Yes

No

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

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

Yes

No

Hospitals / Private Clinics*

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

Yes

No

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

No

How many cigarettes a day?*

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

Yes

No

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

No

Period and name of insurance company*

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

Yes

No

Period and type of insurance policy*

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

Yes

No

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

Yes

No

How many times a week?*

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

Yes

No

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

No

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

Yes

No

What kind of sport do you practice?*

Have you ever been investigated or diagnosed with any form from brain tumor, malignancy, cancer, leukemia, lymphoma or any other form of malignancy?*

Yes

No

Body measures:

Height *

Weight*

Blood pressure (tension):*

Min / Max

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.

Verify if you qualify for Individual health insurance

1. At any time in the past ten years have you been diagnosed with or received treatment of any kind for any of the following diseases:

Any form of cancer, leukemia, Hodgkin's disease, lymphoma, sarcoma or melanoma

PO

JO

Any precancerous lesion, borderline tumor, dysplasia, prostate enlargement or marker for adult blood tumor (PSA)

PO

JO

Hyperthyroidism, the presence of polyps in the colon, small intestine

PO

JO

Abnormal appearance of the cervix or mammogram

PO

JO

Stomach

PO

JO

Any blood disorders or inherited immune disorders that need treatment over a period of more than one month, which required regular or continuous treatment in addition to a special diet

(for example aplastic anemia, lymphoma, leukemia, myeloma, myelodiplastic syndrome, traffic light cell disease, thalassemia)

PO

JO

Any type of Tumor, lump, cyst

PO

JO

Vascular condition or blood circulation including stroke, transient ischemic attack (TIA)

PO

JO

Hemorrhage of the brain (bleeding), abnormal blood vessels (arteriovenous malformation, aneurysm, thrombosis in or around the brain

PO

JO

Any form of heart disease

(for heart attack, angina, heart gene disorders, heart valve disorders, heart murmur or rheumatic fever, heart failure)

PO

JO

Enlargement of the heart or cardiomyopathy.

(You can answer NO if you are only being treated for high blood pressure and / or high cholesterol)

PO

JO

Diabetes

(You can answer NO if you are only being treated for gestational diabetes)

PO

JO

Chronic renal function, dialysis, liver cirrhosis or chronic liver failure

PO

JO

2. Do you have any of your natural parents, siblings, before the 50th birthday, diagnosed with cardiovascular disease (heart attack, bypass surgery or stroke), polycystic kidney disease or cancer of the colon, breast, colon obese, ovarian, prostate, melanoma, pancreas or kidney?

PO

JO

3. Have you experienced or suffered during the last 6 months any persistent or recurrent symptoms and / or signs that have not yet been investigated? This includes any lump in the breast or testicles, rectal bleeding, blood in the urine, unusual cough, jaundice, unexplained weight loss, increasing frequency headaches, vision disturbances (blurring / double vision, unexplained vision loss ) difficulty, weakness of limbs, seizures, abnormal values in blood tests.

PO

JO

4.Are you currently in the appointment process or have you planned a name for the doctor or hospital whose purpose is to share or discuss any of the symptoms mentioned in question 3 above; or are you awaiting the results of tests, procedures or tests for such symptoms or findings?

PO

JO

5. Have you scheduled an appointment for breast magnetic resonance imaging (MRI) over the last 12 months?

PO

JO

6. Have you had or have you been recommended to have or are you currently on the organ transplant waiting list?

PO

JO

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 in good health, with no defects or illnesses or health condition. I declare that I am fully aware that the Insurer will not pay any benefit in the event that the insured event occurs as a direct or indirect result of any defect, health condition, illness or its complication, or injury or wound that existed prior to the insurance start date, regardless of whether the insured had knowledge of it or not. I declare that I have read, known, understood, and accepted the terms of this insurance contract. I authorize any doctor with whom I have consulted or will consult before and after the signing of this application, as well as any hospital, clinic, or public or private care institution that possesses information about me, that the Insurer may contact, even after the occurrence of the insured event, to provide any relevant information, report or document about me. I declare that all the information and answers stated in the “individual health insurance application” are true and accurate and that I have not hidden, excluded or altered any information. I am aware that the data and information requested form part of the insurance contract and that providing false or inaccurate information may lead to the immediate termination of the contract or forfeiture of the compensation arising from this insurance contract. Consent declaration for use of personal data for the purpose of executing the insurance contract:In accordance with Law No. 124/2024 “On the Protection of Personal Data” and European Union Regulation GDPR No. 679/2016 of 27 April 2016, I freely and clearly consent that the insurance company SIGAL, with tax number NUIS J91809007H, located at SIGAL Business Center, Blvd. Zogu I No.1, Tirana, and its authorized personnel may verify and process my personal data.My consent for the verification and processing of personal data is granted to the controller and processor, and includes: Identification data: First name, Last name, ID, address, date of birth, copy of identification document. Health data (sensitive data according to the law and GDPR): medical history; results of medical examinations; diagnoses and treatments; medical records; medical charts and recommendations; medications; medical and pharmaceutical invoices where my sensitive personal data is contained. Financial data: bank account number, transactions.Being fully informed of my rights and obligations under Law No. 124/2024 and GDPR No. 679/2016 of 27 April 2016, I give my consent to the processing of personal data under the conditions described above.

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INDIVIDUAL HEALTH INSURANCE APPLICATION (COMPANY)