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1 Uppgifter
2 Betalnings-uppgifter
3 Hälso-deklaration
4 Ytterligare försäkrade
5 Teckning
Försäkringsansökan DKV
Uppgifter till försäkringstagaren (första försäkrade person)
Hälsning
Betalningsuppgifter
Betalningsmetod
Hälsodeklaration
 Alla sidor måste besvaras i detalj. Ange även symptom, sjukdomar eller konsekvenser av olyckan som du anser vara irrelevanta.  

Personuppgifter av den försäkrade
Konsumtion av
Formulär för hälsofrågor

Skulle svaret vara positivt på någon av följande frågor, lämna ytterligare förklaringar i motsvarande textruta och / eller bifoga detaljerade läkarrapporter.

1. Lider du eller har du lidit av en sjukdom, olycka, medfödd sjukdom, ärftlig sjukdom, ledvärk eller andra symtom eller smärtor?
2. Har du mottagit eller planerar du en kirurgisk, medicinsk, farmakologisk, rehabiliterings- eller dietbehandling (t.ex. diet för patienter med högt blodtryck)?
3. Har du haft sjukhusvistelse eller väntar du på en?
4. Har en diagnos utförts eller planeras en?
Ytterligare försäkrade personer
Uppgifter till den andra försäkrade personen
Hälsning
Konsumtion av

Skulle svaret vara positivt på någon av följande frågor, lämna ytterligare förklaringar i motsvarande textruta och / eller bifoga detaljerade läkarrapporter.

1. Lider du eller har du lidit av en sjukdom, olycka, medfödd sjukdom, ärftlig sjukdom, ledvärk eller andra symtom eller smärtor?
2. Har du mottagit eller planerar du en kirurgisk, medicinsk, farmakologisk, rehabiliterings- eller dietbehandling (t.ex. diet för patienter med högt blodtryck)?
3. Har du haft sjukhusvistelse eller väntar du på en?
4. Har en diagnos utförts eller planeras en?
Uppgifter till tredje försäkrade personen
Hälsning
Konsumtion av

Skulle svaret vara positivt på någon av följande frågor, lämna ytterligare förklaringar i motsvarande textruta och / eller bifoga detaljerade läkarrapporter.

1. Lider du eller har du lidit av en sjukdom, olycka, medfödd sjukdom, ärftlig sjukdom, ledvärk eller andra symtom eller smärtor?
2. Har du mottagit eller planerar du en kirurgisk, medicinsk, farmakologisk, rehabiliterings- eller dietbehandling (t.ex. diet för patienter med högt blodtryck)?
3. Har du haft sjukhusvistelse eller väntar du på en?
4. Har en diagnos utförts eller planeras en?
Uppgifter till fjärde försäkrade personen