TIS: Life Insurance - On-line Application/Quotation Form

Full Name (1)
Gender / Sex

Gender / Sex Male Female
Date of Birth Date of Birth / DD / MM YYYY
Profession
NIE Nº.
Tel./Mob. Number(s)
Email
Full Address & Post Code
Start Date of Policy Start Date of Policy / DD / MM YYYY
Is there a Mortgage

Is there a Mortgage Yes No
Outstanding Amount of Mortgage
Do you ride a Motorcycle 125cc+
Do you do any Professional Sports
Medical Examination Requirements :
up to 45 yrs of age - 200,000€ ............ NO MEDICAL
46-60 years of age - 150,000€ ............ NO MEDICAL
60+ years of age - 90,000€ ................ NO MEDICAL

In all cases a Medical Questionnaire MUST be completed prior to the policy being issued.
Value of Life Cover Required

Value of Life Cover Required 25,000 50,000 75,000 100,000 150,000 200,000 300,000 Other Other
Additional Cover Required

Additional Cover Required None Permanent Total Disability (PTD) Death due to an accident PTD due to a car accident Death due to a car accident PTD due to an accident Critical Illness
IBAN CODE : 24 Characters.
ESxx , plus Bank Account Nº ( 20 Digits 4-4-2-10 )
Beneficiary (if different to Policy Holder)

e.g. Name of Bank and Mortgage Acct Number .......OR
Full Name, NIE or Passport and contact Telephone number
Any Comments, Questions or Suggestions :
Data Protection/Ley de Protección de Datos

Data Protection/Ley de Protección de Datos I agree to the sending and retention of this personal data in compliance with The Data Protection Act. / Estoy de acuerdo con el envío y la retención de estos datos personales de acuerdo con la Ley de Protección de Datos.
Type the letters you see in the image below.