Health Insurance Carrier Street Address 0 øh Health Insurance Proposal Form MAPFRE Middlesea p.l.c. Are you or any dependant/s listed in this Proposal Form residing away from the principal country of residence for more than 180 days in any 12-month policy period? This should normally be within fifteen working days unless the matter is very complicated such as where other organisations need to be  contacted. is the leading insurance company in Malta and a member of the MAPFRE group. Age Name I.D. I undertake to notify MAPFRE Middlesea p.l.c of any change in the information subsequent to the submitting of this proposal form. COMPLAINTSWe are committed to providing good quality services. Additional Information: You can view the Additional Data Protection Information which is available from any MAPFREMiddlesea Plc Office or through www.middlesea.com/insurance-mt/data-protection/. I hereby agree that I have read the policy and am bound by the terms, conditions, limitations and exclusions of the said policy. IMPORTANT NOTEInsurers, their Agents and Insurance Associations share information with each other to prevent fraudulent claims and for underwriting purposes. MAPFRE Middlesea Plc may view the Proposer’s data in files regarding the fulfilment and non-fulfilment of monetary … MAPFRE Middlesea p.l.c. I understand (and have explained to Others) that when I tell the Company about an incident which may or may not give rise to a claim, the Company may pass information relating to it to the Malta Insurance Association and / or other insurance companies and intermediaries. The Proposer consents in turn to the recording of any telephone conversations with the Company regarding the insurance agreement. Controller: MAPFRE Middlesea Plc Purposes: Management of the insurance agreement, creation of profiles for suitable enforcement of the insurance agreement, integral and centralised management of the relation with the MAPFRE Group, and delivery of information and advertising on MAPFRE Group products and services. Both entities are regulated by the MFSA. Middle Sea House, Floriana FRN 1442, Malta T: (+356) 2124 6262 mapfre@middlesea.com middlesea.com. I / we acknowledge that Bonnici Insurance Agency Ltd (BIA) and / or Mapfre Middlesea plc (MMS) may process the personal data that I/we provide … Should you fail to provide the information required herein, MAPFRE Middlesea p.l.c. Both entities are regulated by the MFSA. The Company will seek to resolve the problem immediately. The Proposer declares that he/she is older than eighteen (18) years of age. I am satisfied with the way the proposal form has been completed and if it has been completed by an employee and / or authorised intermediary on my behalf such person, shall, for that purpose, be regarded as my / our agent. In the event of a claim, some or all the information you supply on this form and the proposal form together This record will be passed promptly to the Complaints Officer to deal with. 4. to be completed by a specIalIst Patient’s name Details of the patient’s complaints/symptoms Diagnosis Treatment given … We recognise that a client may not be satisfied with the service provided. It is important to note that we shall not accept liability for a medical condition which arose prior to the proposal date unless such a condition is declared and which Mapfre Middlesea Should the data provided pertain to physical persons other than the Proposer, the latter guarantees that he/she has obtained and has their prior consent for the communication of their data and has informed them, prior to their inclusion in this document, of the purposes of the data processing, communications, and other terms established herein and in the Additional Data ProtectionInformation. England Insurance Agency Ltd. C5556 is authorised as an agent for Mapfre Middlesea p.l.c. Yes No If “YES”, please give details health INSURANCE PROPOSAL FORM Mapfre Middlesea p.l.c. Only need a minimum of information. You can use this general form to contact Middlesea regarding all issues. MAPFRE Middlesea Health Proposal Form. Please provide your IBAN number to … I understand that in the event of a finding of incomplete and/or non-disclosure of material information, MAPFRE Middlesea p.l.c reserves the right to repudiate the claim or declare the policy void. PROFESSIONAL SECRECYI consent on my behalf and on behalf of any other person specified in this form (others), that the Company or any other member of the Group may exchange some or all of the information with my insurance intermediary, appointed experts, other insurance companies or the Malta Insurance Association for the purpose of administering my insurance proposal and policy, handling and settling of claims, detecting, preventing and suppressing fraud and the keeping of statistics. Do you have other current policies with Bonnici Insurance Agency / Mapfre Middlesea plc? Choose department * Your message * Send us a message. Basic data protection informationController: MAPFRE Middlesea PlcPurposes: Management of the insurance agreement, creation of profiles for suitable enforcement of the insurance agreement, integral and centralised  management of the relation with the MAPFRE Group, and delivery of information and advertising on MAPFRE Group products and services. The Proposer is hereby informed and expressly consents, by signing this document, to the processing of the data voluntarily provided in this document, as well as of any data which might be provided to MAPFRE Middlesea Plc or “The company” directly or through an Insurance Intermediary, and those obtained by recording telephone … MMS is authorised under the Insurance Business Act, Cap 403 of the laws of Malta. Cover Details: Is your car registered with Transport Malta? MMS is authorised under the Insurance Business Act, Cap 403 of the laws of Malta. (Company Registration Number C 5553) is a company authorised under the Insurance Business Act, 1998 to carry out long term and general business and is regulated by the Malta Financial Services Authority. best of my knowledge and belief correct and complete and will form the basis of the contract between me and MAPFRE Middlesea p.l.c. It is a subsidiary of the Spanish multinational insurance company MAPFRE. Middle Sea House, Floriana FRN 1442, Malta T: (+356) 2124 6262 mapfre@middlesea… Standing: Execution of the project. HEALTH INSURANCE PROPOSAL FORM SELECT AND SELECT XL National ID Card Proposal no. If the Insured is not happy about writing a letter, the Insured can always ask a member of the Company to take notes of the complaint which the Insured willbe then asked to sign. Your name * your telephone Agents and Insurance Associations share information with each other to prevent fraudulent claims for. 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