INDIVIDUAL HEALTH INSURANCE APPLICATION

This form must be completed by each applicant. If the applicant is under 18 this form must be signed by the parent or guardian. A passport format photo of the applicant must be attached to this application.

A. APPLICANT PERSONAL INFORMATION

Given and Family name*

Given and family name

Birthday*

Date-Month-Year ×

No. ID Cards*

Identity Card No.

Residence*

Residence

E-mail*

E-mail

Civil status (no. Family members)*

Civil status (no. Family members)

Profession / Employer*

Profession / Employer

Contact number*

Contact number

B. Coverage Option

1. Which coverage option do you prefer:*

Standard

Silver

Gold

Kompania

Write here

Note: The questionnaire is valid for a period of 15 days from the date of signing. Premium is quoted according to the required option. If the insurance contract is not signed within this period, the applicant must re-fill out the form and the premium rates become subject to recalculation.

C. APPLICANT HEALTH DATA

Have you had surgery? If yes, specify*

YES

NO

What surgery did you perform?*

Have you ever had a transfusion or blood transfusion? If so, why and when?*

YES

NO

For what reason and when?*

In the last 12 months, have you had any medical checkups?*

YES

NO

Do you currently need any treatment or medication or consultation with a doctor, doctor or physiotherapist?*

YES

NO

Specify for what disease or health condition you are following*

Do you have a private clinic / hospital where you prefer to receive medical services. If yes, specify*

YES

NO

Hospitals / Private Clinics*

Do you travel often? If so, how long do you stay outside Albania?*

YES

NO

How long is the maximum time you stay outside Albania?*

Have you ever been insured with health insurance? If yes, specify the period and the name of the Company?*

YES

NO

Period and name of insurance company*

Do you have existing insurance contracts with SIGAL UNIQA Group Austria? If yes, specify*

YES

NO

Period and name of insurance company*

Do you use contact lenses or glasses?*

YES

NO

Do you practice sports or fitness in your spare time? If so, how many times a week?*

YES

NO

How many times a week?*

Do you have relatives / friends who are provided with SIGAL UNIQA packages? If yes, please mention*

YES

NO

Friends / Family*

Are there any vaccines for children 0-15 years old that you want to buy privately? If so, contact the health department to calculate the additional insurance premium for their coverage. If it does not apply do not click on any of the answers.

YES

NO

Do you practice sports, as an amateur or professional?*

YES

NO

What kind of sport do you practice?*

Body masses:

Length*

Weight*

Blood pressure (tension):*

Min / Max

Year of diagnosis

Treatment period

Results

Check if you qualify to get an extra cover for critical illness and coverage worldwide

The following questions are not mandatory to answer.

1.At any time in the last ten years have you been diagnosed or treated of any kind in connection with any of these diseases:

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

YES

NO

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

YES

NO

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

YES

NO

Abnormal appearance of the cervix or mammogram

YES

NO

Stomach

YES

NO

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

YES

NO

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

YES

NO

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

YES

NO

Any form of heart disease

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

YES

NO

Enlargement of the heart or cardiomyopathy.

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

YES

NO

Diabetes

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

YES

NO

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

YES

NO

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?

YES

NO

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.

YES

NO

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?

YES

NO

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

YES

NO

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

YES

NO

Name of family doctor

The name of the dentist where you regularly attend

The name of the occultist you attend regularly

Where have you heard about this insurance?*

Write here

For any additional information or explanation regarding the above questions, please provide details in the space below and attach to this request a final copy of the medical records.

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 Photo and Documents

I declare that I understand, accept and approve the terms that SIGAL UNIQA Group Austria will not pay benefits for the treatment of diseases, symptoms, or bodily injuries occurring before the date of commencement of (pre-existing) insurance coverage. I also declare that I have answered the above questions correctly and that I understand that this request is part of the insurance contract, and giving incorrect or inaccurate information in it may cause the immediate termination of the contract or the non-receipt of the reward that derives from this insurance contract. I authorize every doctor I have consulted or will consult, before and after signing this request, as well as any hospital, clinic, public or private treatment institution that has medical information about my person, that SIGAL UNIQA Group Austria can contact , even after the occurrence of the insurance event, to provide any relevant information, report or document about me. I also consent and authorize SIGAL UNIQA Group Austria to process information on my personal and sensitive data for insurance and reinsurance purposes and to provide information about me, other institutions for technical, statistical, insurance or reinsurance reasons. Gives consent to the international transfer of personal and sensitive data for security and reinsurance purposes. In any case, the processing of personal data is based on the processing in a fair, fair and lawful manner.

INDIVIDUAL HEALTH INSURANCE APPLICATION