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INDIVIDUAL HEALTH INSURANCE APPLICATION (COMPANY)

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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

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

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

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?*

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

Yes

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

If you don't want to, don't answer any of the following questions.

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

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

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

Abnormal appearance of the cervix or mammogram

Stomach

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)

Any type of Tumor, lump, cyst

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

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

Any form of heart disease

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

Enlargement of the heart or cardiomyopathy.

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

Diabetes

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

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

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?

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.

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?

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

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

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.

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

B. INFORMATION ABOUT HEALTH INSURANCE COVERAGE:

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:

Verify if you qualify for Individual health insurance

If you don't want to, don't answer any of the following questions.

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:

Attach ID Card Photo and medical records if you have

Your form has been successfully submitted

Përshëndetje,

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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

B. INFORMATION ABOUT HEALTH INSURANCE COVERAGE:

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:

Verify if you qualify for Individual health insurance

If you don't want to, don't answer any of the following questions.

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:

Attach ID Card Photo and medical records if you have

Your form has been successfully submitted

Përshëndetje,