FORMULARIO SOLICITUD DE CONTRATACIÓN HOMEDOCTOR

INSURANCE REQUEST

CONTRACT PRODUCT

TARIFF:

SECTOR:

PRODUCT:

COPAYMENT:

START DATE:

HOLDER INFORMATION

NAME:

SURNAME:

SURNAME 2 (Optional):

TITLE:

NIF/ NIE/ PASSPORT:

COUNTRY:

STATE:

TOWN:

POSTAL CODE:

FULL ADDRESS:

E-MAIL:

VERIFY YOUR E-MAIL:

MOBILE PHONE NUMBER:

ANOTHER PHONE NUMBER (Optional):

THE HOLDER, WISH BE INSURED?
YES NO

THE TITULAR, WISH HAVE THE SAME DEVICE LOCATION ADDRESS?
YES NO

THE HOLDER, WILL BE THE PAYER?
YES NO

NUMBER OF INSURED:

DIRECT DEBIT PAYMENT

BANK ACCOUNT HOLDER:

NIF/ NIE/ PASSPORT:

PAYMENT METHOD:

COUNTRY BANK ACCOUNT:

BANK ACCOUNT NUMBER:

PERIODICITY OF PAYMENTS:

MODALITY EQUIPEMENT:

(1). €36/month with a commitment to remain for months 1 to 18. €30/month from the 19th month.
(2). €30/month with no commitment to stay + €125 with the first installment for the deposit of the equipment deposit.

DEVICE LOCATION ADDRESS

COUNTRY:

STATE:

TOWN:

POSTAL CODE:

FULL ADDRESS:

E-MAIL:

PHONE NUMBER:

CLIENT INFORMATION

NAME:

SURNAME:

SURNAME 2 (Optional):

TITLE:

NIF/ NIE/ PASSPORT:

BIRTH DATE:

GENDER:

CIVIL STATUS:

E-MAIL:

MOBILE PHONE NUMBER:

RELATION WITH THE HOLDER

COMMENTS ABOUT THIS REQUEST

DOCUMENTATION

Waiver Agreement

I declare that I know the existence of the document of discontinuance.

I have read and accept the privacy policy, and I consent to the processing of my data.

Copia impresa

INSURANCE REQUEST

CONTRACT PRODUCT

TARIFF:

SECTOR:

PRODUCT:

COPAYMENT:

START DATE:

HOLDER INFORMATION

DIRECT DEBIT PAYMENT

DEVICE LOCATION ADDRESS

CLIENT INFORMATION

COMMENTS ABOUT THIS REQUEST

DOCUMENTATION

OTP SIGN: