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Request for Funeral Insurance Quotes
Details of the Policyholder
NIF / CIF / NIE :
Het is een paspoort
Legal Name:
Contact Person:
Name:
Last Name:
Function:
Department:
DEPARTAMENTOS
Departamento
Sel
1
ADMINISTRACIÓN
2
ATENCIÓN CLIENTE
3
COMERCIAL
4
DIRECCION
5
PRODUCCIÓN
6
SINIESTROS
7
SUSCRIPCIÓN
8
ATENCIÓN MEDIADOR
9
CENTRO ATENCIÓN USUARIO
10
EMISIÓN
Aceptar
Address:
Number:
Postal Code:
Place:
Province:
Telephone:
Email:
Gender:
Choose
Man
Woman
Civil Status:
Choose
Single
Married
Divorced
Widow/Widower
Seperated
Unmarried partner
Occupation:
Country of Birth:
Choose
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of Congo
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Granada
Greece
Greenland
Guadalupe
Guam
Guatemala
Guerney
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See (Vatican)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauricio
Mauritania
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pakistan
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Sahara
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka (Ceylon)
St. Kitts-Nevis (St. Kitts)
St. Lucia
Sudan
Surinam
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
U.S.A.
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands (U.S.)
Yemen
Zambia
Zimbabwe
Birth Date:
:
Other Details:
Foreign Direction
Address:
Number:
Postal Code:
Place:
Province:
Telephone:
Email:
Information about the Insured
Birth Date:
Gender
Name:
Last Name:
NIF / CIF / NIE :
Insured 1
Is the policyholder
Birth Date:
1.
Gender:
Choose
Man
Woman
Is the policyholder
Add another insured
Insured 2
Birth Date:
2.
Gender:
Choose
Man
Woman
Es Pasaporte
Add another insured
Insured 3
Birth Date:
3.
Gender:
Choose
Man
Woman
Es Pasaporte
Add another insured
Insured 4
Birth Date:
4.
Gender:
Choose
Man
Woman
Es Pasaporte
Add another insured
Insured 5
Birth Date:
5.
Gender:
Choose
Man
Woman
Es Pasaporte
Add another insured
Insured 6
Birth Date:
6.
Gender:
Choose
Man
Woman
Es Pasaporte
Other Details
What type of insurance would you like?:
Funeral Service in Spain
Repatriation
Repatriation Country:
Choose
Afghanistan
Albania
Germany
Andorra
Angola
Antigua and Barbuda
Saudi Arabia
Algeria
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belgium
Belize
Benin
Bermuda
Belarus
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Bhutan
Cape Verde
Cambodia
Cameroon
Canada
Chad
Chile
China
Cyprus
Colombia
Comoros
Congo
North Korea
South Korea
Ivory Coast
Costa Rica
Croatia
Cuba
Denmark
Djibouti
Dominica
Ecuador
Egypt
El Salvador
United Arab Emirates
Eritrea
Slovenia
Spain
U.S.A.
Estonia
Ethiopia
Fiji
Philippines
Finland
France
Gabon
Gambia
Georgia
Ghana
Gibraltar
Granada
Greece
Greenland
Guadalupe
Guam
Guatemala
French Guiana
Guerney
Guinea
Equatorial Guinea
Guinea-Bissau
Guyana
Haiti
Netherlands
Honduras
Hong Kong
Hungary
India
Indonesia
Iraq
Iran
Ireland
Iceland
Cayman Islands
Faroe Islands
Falkland Islands
Marshall Islands
Solomon Islands
Virgin Islands (U.S.)
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kyrgyzstan
Kiribati
Kosovo
Kuwait
Laos
Lesotho
Latvia
Lebanon
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malaysia
Malawi
Maldives
Mali
Malta
Morocco
Martinique
Mauricio
Mauritania
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Mozambique
Myanmar (Burma)
Namibia
Nepal
Nicaragua
Niger
Nigeria
Norway
New Caledonia
New Zealand
Oman
Pakistan
Palestine
Panama
Papua New Guinea
Paraguay
Peru
French Polynesia
Poland
Portugal
Puerto Rico
Qatar
United Kingdom
Central African Republic
Czech Republic
Democratic Republic of Congo
Dominican Republic
Slovak Republic
Reunion
Rwanda
Romania
Russia
Sahara
Samoa
St. Kitts-Nevis (St. Kitts)
San Marino
Saint Vincent and the Grenadines
St. Lucia
Holy See (Vatican)
Sao Tome and Principe
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Syria
Somalia
Sri Lanka (Ceylon)
South Africa
Sudan
Sweden
Switzerland
Surinam
Swaziland
Thailand
Taiwan
Tanzania
Tajikistan
East Timor
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turkey
Ukraine
Uganda
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Do you already have an insurance?:
Choose
Yes
No
What is the name of the Insurance Company?:
Choose
ACE EUROPE
ADESLAS
AEGON
AGA INTERNATIONAL, S.A.
AGRUPACIÓ (AMCI)
ALLIANZ
APRIL
ARAG
ARESA
ASEFA
ASISA
ATLANTIDA
AURA
AXA
BUPA
CASER
CATALANA
CHUBB
DIVINA PASTORA
DKV
ERV
EUROP ASSISTANCE
FIATC
FIDELIDADE
GENERALI
LIBERTY
MAPFRE
MGS, SEGUROS Y REASEGUROS, S.A.
NATIONALE NEDERLANDEN
PLUS ULTRA
PREVENTIVA SEGUROS
PREVISION MALLORQUINA
PREVISORA GENERAL
REALE
SANITAS
SANTA LUCIA
VIDACAIXA
ZURICH GALOM
When do you want the insurance to start?:
End Date:
Remarks
Documents
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