DKV Proposal Form Details (Agency Number 0100001289)

Step 1 of 2: Submit

Please complete this form to help us complete as much of your DKV Proposal Form as possible. All fields marked with a red asterisk require a compulsory answer. This form is subject to DKV Approval and no insurance will be in place until confirmation is provided directly from the Insurer (DKV).

Date you wish policy to commence from

Frequency of Premium Payments Policy Holder - NIE (or Passport) Number Policy Holder - First Name(s) Policy Holder - Surname Mobile Telephone Number (preferably Spanish) Policy Holder - E-Mail Address Policy Holder - Date of Birth

Policy Holder - Nationality Policy Holder - Male/Female Policy Holder - Legal Status Landline Telephone Number (if any) Policy Holder - Occupation IBAN Number of Spanish Bank Account where Premiums will be debited Proposed Spanish Address 5-digit Spanish Codigo Province of Spain Are you already an existing DKV Customer DKV Policy Applying For Level of Cover Your weight (in kilograms) Your height (in centimetres) Average number of cigarettes smoked per day (non-smokers please enter ZERO or NON-SMOKER) Average number of units of alcohol consumed per week (non-drinkers please enter ZERO or NONE) Do you take any illegal drugs or substances Your eyesight - please select the option below that best describes your eyesight Do you have, or have you had, any kind of illness, accident, congenital defect, hereditary family illness, painful joints or any symptoms or severe pain? Have you received, are you receiving, or are you about to receive any kind of surgical, medical, pharmaceutical, rehabilitating or dietetic treatment. Cause and dates. Please list here any prescribed medication(s) that you take and what they control. Have you ever been, or are you about to be, admitted to hospital? (State type of test, motive, result and date) Have you had, or are you about to have, any diagnostic tests? (State type of test, motive, result and date)