male male - Pantaenius

Application Form for an International Health Insurance
for Longterm Sailor
Policyholder
First name
Last name
Date of birth
Gender
□ male
□ female
Address
Telephone
Home country
Nationality
Height
Weight
Name of the yacht
E-mail
(Please state your e-mail address, so that we can provide you with all information regarding this insurance.)
BEGIN DATE OF INSURANCE COVER:
(earliest inception date can be upon receival of your application)
Person Insured (if not identical with the policyholder)
First name
Last name
Date of birth
Gender
□ male
□ female
Address
Telephone
Home country
Nationality
Height
Weight
PANTAENIUS SPAIN S.L. - AGENCIA VINCULADA DE SEGUROS NÁUTICOS
C/ Torre de Pelaires, 5 · 07015 Palma de Mallorca · España · Tel. +34-971 70 86 70 · Fax +34-971 70 86 71 · www.pantaenius.com · [email protected]
NIF: B 57392466 · Registro Mercantil de Palma de Mallorca, Tomo 2184, Folio 76, Hoja PM-53228, Inscripción 1
Registrada en la D. G. del Tresor i Política Financera del Govern de les Illes Balears, expediente IB-AVJ006-MA. R.C. contratada con AXA Seguros Generales S.A. y capacidad
financiera conforme a la Ley.
Policy Holder
Name
DECLARATION ON THE FOLLOWING DISEASES
I declare herewith, that I do not suffer or have not suffered from one of these diseases:
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Any form of cancer
Organ failure
Any form of organ / tissue transplant
HIV or other syndromes related to the immune system
Syndromes in relation to the hematopoietic (blood forming) system
Coagulation (bleeding) disorders
Multiple sclerosis
Cystic fibrosis
Insulin dependent diabetes
Chronic hepatitis
Growth hormone deficiency
Infertility
Any other material condition. A material condition is one which requires a period of hospitalisation,
recurrent or continuous medical attention. If you have any doubt whether a condition is material
you should disclose it.
IF YOU SUFFER OR HAVE SUFFERED FROM ONE OF THESE DISEASES, PLEASE GIVE FULL DETAILS ON THE FOLLOWING
PAGE.
DECLARATION:
To the best of my knowledge the information provided on this application form, whether in my own hand or not, is true
and complete. I understand that failure to disclose, or misrepresentation of any pertinent facts may lead to the denial
of a claim or cancellation of any policy. I understand and agree that this application and the statements contained
herein shall form the basis of the contract issued as a result of this application.
The Insured agrees that Pantaenius will save the personal data and will give the data to the participating underwriters
and re-insurer(s) and that Pantaenius is entitled to change underwriters. Please refer to the attached text concerning
data protection for detailed information.
Place/Date
Place/Date
Signature Policy Holder
Please send with original signature to Pantaenius.
Signature Person Insured
Please send with original signature to Pantaenius.
PANTAENIUS SPAIN S.L. - AGENCIA VINCULADA DE SEGUROS NÁUTICOS
C/ Torre de Pelaires, 5 · 07015 Palma de Mallorca · España · Tel. +34-971 70 86 70 · Fax +34-971 70 86 71 · www.pantaenius.com · [email protected]
NIF: B 57392466 · Registro Mercantil de Palma de Mallorca, Tomo 2184, Folio 76, Hoja PM-53228, Inscripción 1
Registrada en la D. G. del Tresor i Política Financera del Govern de les Illes Balears, expediente IB-AVJ006-MA. R.C. contratada con AXA Seguros Generales S.A. y capacidad
financiera conforme a la Ley.
Policy Holder
Name
NAME OF DOCTOR
DETAILS OF CONDITION
DATE OF TREATMENT
DETAILS OF TREATMENT
CURRENT STATE OF HEALTH
DECLARATION:
I authorise any doctor, who has ever attended me, to provide the Insurer with any information that may be required
including prior medical history.
We wish to apply for the above specified insurance cover. We have read and understood the content and conditions
for the Pantaenius International Healthcare Plan for Longterm Sailors and accept them as part of the contract which
comes into effect on the basis of this application and which will be completed for each insured person. We confirm, that
the information we have provided is true and complete to the best of our knowledge.
Place/Date
Signature Person Insured
PANTAENIUS SPAIN S.L. - AGENCIA VINCULADA DE SEGUROS NÁUTICOS
C/ Torre de Pelaires, 5 · 07015 Palma de Mallorca · España · Tel. +34-971 70 86 70 · Fax +34-971 70 86 71 · www.pantaenius.com · [email protected]
NIF: B 57392466 · Registro Mercantil de Palma de Mallorca, Tomo 2184, Folio 76, Hoja PM-53228, Inscripción 1
Registrada en la D. G. del Tresor i Política Financera del Govern de les Illes Balears, expediente IB-AVJ006-MA. R.C. contratada con AXA Seguros Generales S.A. y capacidad
financiera conforme a la Ley.
The Right to Information in accordance with the law 26/06 concerning mediation of private
insurances and reinsurance and Law 15/99 concerning personal data protection by the Company Pantaenius Spain S.L.
In compliance with the Organic Law 15/1999 of 13 December for the protection of personal data, we
advise you that your personal data will be introduced in our records of Potential Clients or, had some
product already been contracted with us, in the existing clients file, or open files or prospective commercial file, duly inscribed in the General Register of protected Data pertaining to the Spanish Data Protection Agency. The purpose of the collection and processing of data is to manage the business relationship,
insurance applications and also the issuing of policies, handling claims and hiring of professional services
such as surveyors, lawyers, doctors, etc and any other service necessary for the effective discharge of
our duties, professional and commercial activities of assessment, assistance and mediation in insurance
matters. The client expressly authorises the Agency to cede the necessary data for said mediation activity. As such, the informed consent of the client is implicit.
Likewise, the data will be used for publicity campaigns and commercial promotions about the products
and services of Pantaenius Spain S.L.
Your consent to the processing of data both for application of insurance products and services, such as
advertising and trade promotion, is implicitly understood and provided demonstrably and unequivocally,
by communication of this data to Pantaenius Spain S.L. If your data has been obtained from publicly
available sources or by any third party, and you have received information about our Company, we would
understand that you are authorising us to send commercial propositions or publicity campaigns, should
no direct objection be received from you.
Publicity can be carried out by any method including telephone calls, by post, messages, email or internet.
In compliance with Law 26/06 regarding Insurance Mediation, Pantaenius Spain S.L. is in the process of
requesting all relevant information for the issuance of the policy requested. The transfer of data to the
insurance company is compulsory and the refusal to comply precludes the provision of services by Pantaenius Spain S.L.
The data provided may be used at a future date for the contracting of other products or services that
could be of interest to the client.
In order to use your right to access, modification, cancellation or opposition to the processing of your
data, please contact us at Pantaenius Spain S.L., Torre Pelaires 5, Palma de Mallorca in the manner of
your choice, stating which right you wish to exercise, accompanied by a photocopy of your national identity document, in order to confirm that you are the interested party who is exercising their right to the
changes in question.
PANTAENIUS SPAIN S.L. - AGENCIA VINCULADA DE SEGUROS NÁUTICOS
C/ Torre de Pelaires, 5 · 07015 Palma de Mallorca · España · Tel. +34-971 70 86 70 · Fax +34-971 70 86 71 · www.pantaenius.com · [email protected]
NIF: B 57392466 · Registro Mercantil de Palma de Mallorca, Tomo 2184, Folio 76, Hoja PM-53228, Inscripción 1
Registrada en la D. G. del Tresor i Política Financera del Govern de les Illes Balears, expediente IB-AVJ006-MA. R.C. contratada con AXA Seguros Generales S.A. y capacidad
financiera conforme a la Ley.