Health Insurance Policies for Schengen Tourist Visa Health Insurance PoliciesTo apply for the Health Insurance Policy for a Tourist Visa, please complete the form in full and submit it The intermediary declares that they have delivered to the Policyholder, by email or in paper format (according to the Policyholder’s choice), the Pre-contractual Information Set relating to the chosen insurance product, as required by the European Insurance Distribution Directive EU 2016/97 (IDD). The Policyholder acknowledges, on their own behalf and on behalf of any other insured persons covered by this policy: that the proposed product – considering the destination and type of trip – meets and is appropriate to the specific insurance needs related to the insured persons’ state of health and the type of travel service purchased that they have not already taken out another policy covering the same risks for the trip covered by this insurance Do you acknowledge, understand and accept limitations, deductibles, exclusions of coverage, and the procedures and timeframes for submitting a claim? Additional Insured Persons Number of Insured 123More than 3 Start of Trip End of Trip The end date must be the same or later than the start date. Policyholder Data Type: Private IndividualCompany Full Name Tax Code Nationality AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaSaudi ArabiaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelgiumBelizeBeninBhutanBelarusMyanmarBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeChadChileChinaCyprusColombiaComorosCongoNorth KoreaSouth KoreaIvory CoastCosta RicaCroatiaCubaDenmarkDominicaEcuadorEgyptEl SalvadorUnited Arab EmiratesEritreaEstoniaEswatiniEthiopiaFijiPhilippinesFinlandFranceGabonGambiaGeorgiaGermanyGhanaJamaicaJapanDjiboutiJordanGreeceGrenadaGuatemalaGuineaGuinea-BissauEquatorial GuineaGuyanaHaitiHondurasIndiaIndonesiaIranIraqIrelandIcelandMarshall IslandsSolomon IslandsIsraelItalyKazakhstanKenyaKyrgyzstanKiribatiKuwaitLaosLesothoLatviaLebanonLiberiaLibyaLiechtensteinLithuaniaLuxembourgNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMoroccoMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMozambiqueNamibiaNauruNepalNicaraguaNigerNigeriaNorwayNew ZealandOmanNetherlandsPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPolandPortugalQatarUnited KingdomCentral African RepublicCzech RepublicDemocratic Republic of the CongoDominican RepublicRomaniaRwandaRussiaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoHoly SeeSão Tomé and PríncipeSenegalSerbiaSeychellesSierra LeoneSingaporeSyriaSlovakiaSloveniaSomaliaSpainSri LankaUnited States of AmericaSouth AfricaSudanSouth SudanSurinameSwedenSwitzerlandTajikistanThailandTaiwanTanzaniaEast TimorTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUkraineUgandaHungaryUruguayUzbekistanVanuatuVenezuelaVietnamYemenZambiaZimbabwe Date of Birth The policyholder must be of legal age (18+) and have legal capacity. Address ZIP Code City Province Email Mobile Phone Insured People Name first insured person Name second insured person Name third insured person Other insured people
