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1 Datos
2 Datos de pago
3 Declaración de salud
4 Asegurados adicionales
5 Contratar
Solicitud de Seguro DKV
Información sobre el tomador y primer asegurado
Título
Datos de pago
Periodo
Declaración de salud

Todas las páginas se responderán detalladamente. Añada incluso las molestias, enfermedades o secuelas de accidentes que considere intrascendentes.


Datos personales del asegurado / asegurados
Consumo de
Cuestionario de salud

Si en alguna de las siguientes preguntas, la respuesta es positiva, amplíe la información en la línea correspondiente, en el cuadro que encontrará a continuación del cuestionario y/o aporte información médica detallada.

1. ¿Tiene o ha tenido alguna enfermedad, accidente, alteración congénita, enfermedad familiar hereditaria, dolores articulares así como algún otro síntoma o dolor?
2. ¿Ha recibido, recibe o está pendiente de recibir algún tipo de tratamiento quirúrgico, médico, farmacológico, rehabilitador o dietético (Ej: Dieta Hipertensos)?
3. ¿Ha estado hospitalizado o está pendiente de hospitalización?
4. ¿Le han realizado o tiene pendiente de realización alguna prueba diagnóstica?
Asegurados adicionales
Datos del segundo asegurado
Título
Consumo de

Si en alguna de las siguientes preguntas, la respuesta es positiva, amplíe la información en la línea correspondiente, en el cuadro que encontrará a continuación del cuestionario y/o aporte información médica detallada.

1. ¿Tiene o ha tenido alguna enfermedad, accidente, alteración congénita, enfermedad familiar hereditaria, dolores articulares así como algún otro síntoma o dolor?
2. ¿Ha recibido, recibe o está pendiente de recibir algún tipo de tratamiento quirúrgico, médico, farmacológico, rehabilitador o dietético (Ej: Dieta Hipertensos)?
3. ¿Ha estado hospitalizado o está pendiente de hospitalización?
4. ¿Le han realizado o tiene pendiente de realización alguna prueba diagnóstica?
Datos del tercer asegurado
Título
Consumo de

Si en alguna de las siguientes preguntas, la respuesta es positiva, amplíe la información en la línea correspondiente, en el cuadro que encontrará a continuación del cuestionario y/o aporte información médica detallada.

1. ¿Tiene o ha tenido alguna enfermedad, accidente, alteración congénita, enfermedad familiar hereditaria, dolores articulares así como algún otro síntoma o dolor?
2. ¿Ha recibido, recibe o está pendiente de recibir algún tipo de tratamiento quirúrgico, médico, farmacológico, rehabilitador o dietético (Ej: Dieta Hipertensos)?
3. ¿Ha estado hospitalizado o está pendiente de hospitalización?
4. ¿Le han realizado o tiene pendiente de realización alguna prueba diagnóstica?
Datos del cuarto asegurado
Título
Consumo de

Si en alguna de las siguientes preguntas, la respuesta es positiva, amplíe la información en la línea correspondiente, en el cuadro que encontrará a continuación del cuestionario y/o aporte información médica detallada.

1. ¿Tiene o ha tenido alguna enfermedad, accidente, alteración congénita, enfermedad familiar hereditaria, dolores articulares así como algún otro síntoma o dolor?