Interasco - Immigrants application form


  210-6793222 (Monday-Thursday 09:00-17:00, Friday: 09:00-16:00)
  [email protected]
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Elements signed with (*) are required
BEFORE YOU PROCEED PLEASE BE INFORMED ABOUT THE INSURANCE PROGRAM INFORMATION DOCUMENT HERE

APPLICATION FOR HEALTH INSURANCE
HOSPITALIZATION IN PUBLIC HOSPITALS OF GREECE - CAPITAL: 10.000€ ANNUALLY AND 20% CO-INSURANCE
DEATH DUE TO ACCIDENT - CAPITAL: 15.000€ ANNUALLY AND 20% CO-INSURANCE
TOTAL/PERMANENT DISABILITY DUE TO ACIDENT - CAPITAL: 15.000€ ANNUALLY AND 20% CO-INSURANCE
ACCIDENT/SICKNESS EXPENSES PER INCIDENT - CAPITAL: 1.500€ ANNUALLY AND 20% CO-INSURANCE
EUROBANK
GR9402602380000290200607897
PIRAEUS BANK
GR2301720550005055063587769
ALPHA BANK
GR2801403590359002320005763
NATIONAL BANK OF GREECE
GR1301106140000061447050099
POLICY START DATE:
FIRSTNAME:
SURNAME:
DATE OF BIRTH:
CITIZENSHIP:
PROFESSION:
PASSPORT NUMBER:
V.A.T. NUMBER:
TAX OFFICE:
IDENTITY CARD NUMBER:
GENDER:
MALE  
FEMALE  
EMAIL:
RELATIONSHIP WITH POLICY HOLDER:
CONTACT ADDRESS:
TOWN:
STREET:
Nr.:
POSTAL CODE:
PHONE NUMBER:
MOBILE PHONE NUMBER:
BENEFICIARIES (NAME-RELATIONSHIP):
POLICY HOLDER (IN CASE THE POLICY HOLDER IS DIFFERENT FROM THE INSURED):
FIRSTNAME:
SURNAME:
DATE OF BIRTH:
CITIZENSHIP:
PROFESSION:
PASSPORT NUMBER:
V.A.T. NUMBER:
TAX OFFICE:
IDENTITY CARD NUMBER:
GENDER:
MALE:  
FEMALE:  
EMAIL:
CONTACT ADDRESS:
TOWN:
STREET:
Nr:
POSTAL CODE:
PHONE NUMBER:
MOBILE PHONE NUMBER:

Medical History
Deny all   
1. Have you ever been hospitalized or undergone surgery or diagnosed due to pathology or/and undergone medication?
 YES       NO 
2. Have you ever been diagnosed due to surgical or pathological issue or undergone hospitalization or medication or have you ever had symptoms related to: (Autocomplete)
 YES       NO 
2.1. Vassal System
 YES       NO 
2.2. Tumors or cancer
 YES       NO 
2.3. Diabetes
 YES       NO 
2.4. Neurological or Psychological disease
 YES       NO 
2.5. Vassal/ischemic stroke / Brain paralysis
 YES       NO 
2.6. Addiction to drugs or any other substances
 YES       NO 
2.7. Contagious or Infectious diseases (such as AIDS)
 YES       NO 
2.8. Urinary system/genetic system, Renal failure or Intestinal system
 YES       NO 
2.9. Muskuloskeletal system
 YES       NO 
2.10. Ear/throat diseases or Respiratory diseases
 YES       NO 
2.11. Endocrinal diseases
 YES       NO 
2.12. Autoimmune diseases (e.g. Lupus)
 YES       NO 
2.13. Benign tumor(e.g. lipoma)
 YES       NO 
2.14. Coccyx bladder, Hemorrhoids, varicose veins, Phlebitis, Fistula, Hermia
 YES       NO 
2.15. Other diseases (e.g. dermatological or hematology diseases, hepatitis, allergies, immune system disorders)
 YES       NO 
2.16. Congenital Deformity or Diseaseis
 YES       NO 
2.17. Down syndrome, Autism, Gaucher Disease
 YES       NO 
2.18. Treated neurological or psychological diseases
 YES       NO 
2.19. Cholesterol
 YES       NO 
2.20. Gynecological diseases (haemorrhages, cysts, tumors, endometriosis, breast diseases etc.)
 YES       NO 
3. Have you had symptoms for the last ten (10) years for which you did not see a doctor?
 YES       NO 
4. Do you smoke or consume alcohol?
 YES       NO 
5. Did you have any weight changes within the last year?
 YES       NO 
6. Are you an athlete in a professional or amateur club or are you involved in extreme sports?
 YES       NO 
Height (cm):
Weight (kg):
If any of your answers in the above questions is yes, please explain in the details the nature of the disease or trauma. Responses for minors are given by parents/legal guardians. In case of at least one positive answer we will call you back regarding your policy.
Declaration by the applicant
1. With this statement I declare that all the information I wrote on this application are accurate and complete. If any of the information I gave is incorrect or incomplete, Interasco is free frm any commitment and obligation towards me.
2. With this I declare, agree and undertake that:
2.1 All my answers are accurate and complete and I provide then with free will.
2.2 The answers and every other information which will be given to Interasco, will be used as basic condition for the policy between Interasco and I and it will be a part of it.

DECLARATION BY THE APPLICANT
I hereby declare that all the details provided in this Health Declaration Form are accurate and complete. If any of the details I filled in prove to be inaccurate or incomplete, Interasco S.A.G.I. shall be considered released from any commitments and obligations towards me.
The answers set out in the Health Declaration Form and any other information provided to Interasco S.A.G.I. shall be used as a fundamental prerequisite for the Insurance Policy between Interasco S.A.G.I. and me, and shall form an integral part thereof.
I hereby declare, acknowledge and undertake that:
1.1. All the answers I have given are accurate and complete and I have provided them with my own will.
1.2. I am aware of the terms of the policy and especially the exceptions.
1.3. I am aware that every coverage has its own waiting period.
1.4. The insurer reserves the right to accept or reject the proposal without any need to justify its decision. I am fully aware that the Insurance Policy shall enter into force only after the company issues a contract, and after the full payment of the first instalment of the premium.
1.5. I was provided with the forms of INTERASCO S.A.G.I. accompanying this insurance proposal and, more specifically, I have read and have been fully informed of the information contained:
- in the Information Sheet below as per Article 150, L. 4364/2016,
- in the form “Information on Personal Data Protection-Declaration of Consent” issued by INTERASCO S.A.G.I. as Data Controller, pursuant to General Data Protection Regulation 679/2016 (GDPR), which I sign, having been fully informed of the processing of my personal data and my respective rights thereunder,
- in the Insurance Product Information Form.
1.6  To be informed on my insurance application and on the receipt of the insurance policy that shall be issued hereunder, as well as all related documents:
  I agree to receive information on all of the above electronically, at the email address I provide on the first page of this statement or any other address I may provide in writing in the future, or through the website www.interasco.gr and my respective account therein,
OR
  I wish to receive these documents in hard copy.
Payment of the premium through direct bank debit or by credit card and quick payment is provided in cooperation with other entities, namely banks, the Hellenic Post etc. The company shall not be liable for any damage caused by the fault of such entities or their employees at any stage of the relative process.
After being provided with the relative information, I, the undersigned, give my express and unreserved consent to the Company to process my personal data mentioned in this application and in the insurance policy for the purposes of the insurance contract within the meaning of L. 2472/97. Regarding the process of direct bank debit or payment by credit card debit and quick payment, entities collaborating with the company, such as DIAS SA, intermediary bank, account holding bank, the Hellenic Post etc., may also be considered recipients of the personal data.
INFORMATION SHEET UNDER ARTICLE 150, PAR. 1 OF L. 4364/2016
1. Insurance Company Name:
Interasco S.A.G.I. General Insurance Public Limited Company
2. Applicable law.
The insurance contract is governed by Greek law, given that the insured risk at the time of conclusion of the contract is in Greece and the insured party has his/her habitual residence, primary place of activity or head office, in Greece.
3. Manner and time of handling insured parties' written complaints.
- Complaints may be submitted by email at [email protected] by fax at +30 210 6776035 or by post at the address of the Company's headquarters, to the attention of the Company's Complaints Officer. The complaint management process and contact information are posted at the company's official website https://www.interasco.gr/Επικοινωνία.
- Within a reasonable period of time, not exceeding 50 calendar days, the Company shall duly undertake the settlement of written complaints, responding in writing and providing justification to the claimant. If it is unable to respond within the above time frame, the Company shall explain in writing the reasons for the delay, giving an approximate estimated time of completion.
- If a complaint is not satisfied, the claimant may bring the matter before the competent authorities, such as the Bank of Greece or the Consumer’s Ombudsman, or any other third-party institution, without prejudice to his/her ability to bring the matter before the competent Courts, where the problem is not resolved out of court.
DECLARATIONS OF CONSENT
Processing of special categories of personal data
I expressly consent to the collection and processing of special categories of my personal data and to keep them in one or more records within the meaning of the law. In the case of an insured minor under 15 years of age, this consent is also validly given in my capacity as parent or guardian of the minor, thereby accepting the above processing as lawful.
  Yes, I give my consent
I give my express consent and permission to the insurance fund of which I am a member and/or its medical institutions, as well as to any physicians and other medical institutions and hospitals and/or to any insurance companies and/or any other institution or other entity or natural person to provide INTERASCO S.A.G.I. with all the information, including my personal data and those contained in the Electronic Health Insurance File kept by EOPYY, without exception, and in the manner requested by the Company, regarding the condition of my health and/or any disease from which I have suffered in the past and/or from which I am suffering is at the moment and/or from which I will suffer in the future. I hereby release INTERASCO S.A.G.I. from the obligation to maintain medical confidentiality and I waive of this confidentiality with respect to INTERASCO S.A.G.I. This waiver is binding for me and my legal representatives, as well as any of my special or universal successors.
  Yes, I give my consent
Processing data for marketing purposes
I was explicitly informed that INTERASCO S.A.G.I. shall collect, store and process my data for the purpose of carrying out targeted marketing or product promotion activities of the Company or of other companies belonging to the same group, or for the purpose of conducting research on the quality of the services provided by it and I give my explicit consent to this end. To achieve the above objective, my data may be transferred to affiliated survey companies and promotional companies. Under this processing, I was informed of my right to object to it at any time, by sending a relative request to the contact details of INTERASCO S.A.G.I.
  I consent

  I don't consent
DECLARATION OF KNOWLEDGE
I hereby declare that by reading this document I have received complete and clear information on the processing of my personal data as necessary and I give my express and explicit consent to INTERASCO S.A.G.I. insurance company for the above totally legal processing of my data for the purpose of executing my request, or insurance contract between us and the obligations arising therefrom, and more particularly I became aware of my right to withdraw my consent at any time, as well as of the consequences of any withdrawal.
Price (€):  

Attach copy of identification document (ID, Passport) with file extension pdf, jpeg, jpg, png and size up to 15MB
   
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