Health insurance application form

    Health Insurance Application Form
    1. Nationality:

    2. Address in Greece
    3. Do you spend time abroad? YesNo
      If yes, approximately how many months per year?
    4. Heart, Hypertension, Arteries and VeinsLungsStomach, Intestines, Bile, Gall, Liver, PancreasΚidneys, BladderProstateBrain, Psychiatry diseasesSpine, Muscles, Bones, Joints, Rheumatic diseasesSkin diseases, Cholesterol, Diabetes, ThyroidEyes and EarsBlood diseases, Spleen, Lymph nodes'CancerGynaecology and breast diseasesOther
    5. YesNo
    6. YesNo
    7. YesNo If yes, how many cigarettes per day?

    8. If you answered yes in any of the above cases please elaborate
    9. Debit / Credit CardBank deposit / e-BankingOther
    10. Monthly payments (require debit/credit card)3-month payments6-month paymentsAnnual payment

    11. In case of Debit / Credit card payment please let us know an appropriate date and time for us to call and collect your details(Monday - Friday, 9:00 - 14:00)
    12. Please state the name and details of at least two people in Greece who we can get in touch with in case of an emergency. Ideally, please choose people not living with you

    13. Upload a copy of your passport or ID and a paper showing your AFM (utility bill, tax return or an AFM certificate)


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