Please select the questionnaire for the insurance you are interest in

Personal Data


Health Data


  • Cardiovascular diseases

  • Heart Attack

  • Angina

  • Varicose veins

  • Skin disease

  • Digestive diseases

  • Ulcer in the stomach or duodenum

  • Diaphragmatic hernia

  • Endocrine disorders

  • Diabetes

  • Goiter

  • Gout disorders

  • Urogenital diseases

  • Renal colic (stones)

  • Hysterectomy (removal of the uterus/ovaries)

  • Renal insufficiency

  • Liver disease

  • Hepatitis

  • Cirrhosis

  • Biliary colic, liver colic or gallstones

  • Diseases of bone/muscle

  • Disc prolapse

  • Rheumatism

  • Arthrosis

  • Osteoporosis

  • Knee and meniscus injuries

  • Neurological diseases

  • Brain embolism/thrombosis

  • Epilepsy

  • Meningitis

  • Paralysis

  • Depression

  • Other neurological diseases

  • Diseases of the respiratory tract

  • Asthma

  • Chronic Bronchitis

  • Pneumonia

  • Tuberculosis

  • High blood pressure

  • Tumours

  • Eye disorders and visual disturbances

  • Diseases or disorders of the nose

  • Suffering or suffered from diseases that are not listed

  • Suffering or suffered injuries affecting physical disorders

  • The impact and/or limitations associated with the disease (disability, etc.)

  • Consumption of tobacco

  • Do you take any medicine?

  • Take a drug?

  • Have you ever suffered an injury or accident?

  • Past surgical procedures

  • Have you had an HIV test?

  • Have you seen a doctor in the last 6 months?

  • Have you had an examination with diagnosis or before a treatment?


Personal Data


Personal Data


General data on buildings and land or apartment


Other installations




Insurance limits




Personal Data


Car Data


Personal Data


Boat Data


Personal Data


Personal Data


Personal Data


Commercial Data