Project Description

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1 Details
2 Bank details
3 Health declaration
4 Other insured persons
5 Final step
DKV Application
Details of the policyholder
Gender
Bank details
Payment method
Health declaration
All pages need to be answered in full. Please state in full even those complaints, illnesses or consequences of accidents you consider to be negligible.

Personal details of each insured
Consumption of
Medical questionaire

If the answer to any of the following questions is positive, please enter further explanations in the corresponding text field (i.e. in the additional space) and/or enclose detailed medical reports.

1. Do you suffer or have you suffered from an illness, accident, congenital disorder, hereditary disease, joint pain or among others symptoms or pain?
2. Have you received any surgical, medical, pharmacological, treatments or are you receiving rehabilitation or dietary treatment such as a diet (e.g. for high blood pressure patients)?
3. Have you had hospital stays or are you waiting for one?
4. Has a diagnostic examination been carried out or is one planned?
Additional insured person(s)
Details of the second insured person
Gender
Consumption of

If the answer to any of the following questions is positive, please enter further explanations in the corresponding text field (i.e. in the additional space) and/or enclose detailed medical reports.

1. Do you suffer or have you suffered from an illness, accident, congenital disorder, hereditary disease, joint pain or among others symptoms or pain?
2. Have you received any surgical, medical, pharmacological, treatments or are you receiving rehabilitation or dietary treatment such as a diet (e.g. for high blood pressure patients)?
3. Have you had hospital stays or are you waiting for one?
4. Has a diagnostic examination been carried out or is one planned?
Details of the third insured person
Gender
Consumption of

If the answer to any of the following questions is positive, please enter further explanations in the corresponding text field (i.e. in the additional space) and/or enclose detailed medical reports.

1. Do you suffer or have you suffered from an illness, accident, congenital disorder, hereditary disease, joint pain or among others symptoms or pain?
2. Have you received any surgical, medical, pharmacological, treatments or are you receiving rehabilitation or dietary treatment such as a diet (e.g. for high blood pressure patients)?
3. Have you had hospital stays or are you waiting for one?
4. Has a diagnostic examination been carried out or is one planned?
Details of the fourth insured person
Gender
Consumption of