Project Description

Nu online een contract afsluiten

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1 Gegevens
2 Betalings-gegevens
3 Gezondheids-verklaring
4 Overige verzekerden
5 Voltooiing
DKV-verzekeringsaanvraag
Gegevens over de verzekeringnemer (1. verzekerde persoon)
Begroeting
Betalingsgegevens
Betaalwijze
Gezondheidsverklaring
Alle pagina's moeten in detail worden beantwoord. 
Vermeld ook de klachten, ziekten of de gevolgen van een ongeluk dat u als onbeduidend beschouwt. 

Persoonlijke gegevens van de verzekerde(n)
Consumptie van
Gezondheidsvragenlijst

Als het antwoord op een van de volgende vragen positief is, voer meer uitleg in het corresponderende tekstveld bij, en/of gelieve gedetailleerde medische rapporten bij te voegen.

1. Heeft u, of was er een ziekte, een ongeval,aangboren stoornis,erfelijke ziekte, gewrichtspijn of lijd onder andere Symptomen of pijn?
2. Heeft u een chirurgische, medische, farmacologische, een revalidatie of dieetbehandeling gekregen of is er zo'n dieet voorzien (bijv. voor hypertensieve patiënten)?
3. Hebt u een ziekenhuisopname gehad of wacht u op een verblijf in het ziekenhuis?
4. Is er een diagnostisch onderzoek uitgevoerd of is dit gepland?
Andere verzekerde personen
Gegevens van de tweede verzekerde persoon
Begroeting
Consumptie van

Als het antwoord op een van de volgende vragen positief is, voer meer uitleg in het corresponderende tekstveld bij, en/of gelieve gedetailleerde medische rapporten bij te voegen.

1. Heeft u, of was er een ziekte, een ongeval,aangboren stoornis,erfelijke ziekte, gewrichtspijn of lijd onder andere Symptomen of pijn?
2. Heeft u een chirurgische, medische, farmacologische, een revalidatie of dieetbehandeling gekregen of is er zo'n dieet voorzien (bijv. voor hypertensieve patiënten)?
3. Hebt u een ziekenhuisopname gehad of wacht u op een verblijf in het ziekenhuis?
4. Is er een diagnostisch onderzoek uitgevoerd of is dit gepland?
Gegevens naar de derde verzekerde persoon
Begroeting
Consumptie van

Als het antwoord op een van de volgende vragen positief is, voer meer uitleg in het corresponderende tekstveld bij, en/of gelieve gedetailleerde medische rapporten bij te voegen.

1. Heeft u, of was er een ziekte, een ongeval,aangboren stoornis,erfelijke ziekte, gewrichtspijn of lijd onder andere Symptomen of pijn?
2. Heeft u een chirurgische, medische, farmacologische, een revalidatie of dieetbehandeling gekregen of is er zo'n dieet voorzien (bijv. voor hypertensieve patiënten)?
3. Hebt u een ziekenhuisopname gehad of wacht u op een verblijf in het ziekenhuis?
4. Is er een diagnostisch onderzoek uitgevoerd of is dit gepland?