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  • Health Insurance Proposal Form

  • You must disclose any information that may influence the underwriter’s decision to accept your proposal. If you’re unsure whether something is a material fact, it’s best to disclose it for your own protection. Failing to do so could invalidate your policy or lead to your claims being declined. In terms of a health insurance policy, material facts include but are not limited to: 

    • Your country of residence
    • Any pre-existing medical conditions
    • Any medical treatment, surgery or medication within the last 5 years

    All persons included in this application must reside at the applicant’s address.

    You should not sign this proposal form and its statements or declarations before you have read and understood them. If this document is being completed by someone else on your behalf, please ensure that the details on it accurately reflect what you have said and that the contents have been fully explained to you.

    Completion of this proposal form does not confirm the start of coverage. The effective date of coverage will be specified in the policy schedule, which will be sent to you upon approval of your application. A receipt will only indicate that premium payment has been received, not that the insurance coverage has started or been accepted.

  • Main applicant details

  • Personal Identification Type*
  • Valid to
     - -
  • Nationality*
  • Date of Birth*
     - -
  • Gender*
  • Contact Number*
  • Country of residence? (where you reside for more than 180 days in any 12 month policy period) *
  • Will you or any dependant named in this proposal reside outside of Malta for more than 180 days in any 12-month policy period?*
  • Do you or any of your dependants named in this proposal have, or previously had, health insurance cover with any other insurer, including Mapfre Malta?*
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  • Main applicant - cover and medical details

  • Health Scheme Required*
  • Type of cover*
  • Would you like to apply for an excess on your cover ?*
  • Basic Health Scheme Extensions
  • Basic Health Scheme Extensions
  • Hospital Health Scheme Extensions
  • Health Scheme Extensions
  • International Health Scheme Extensions

  • Within the last five years, have you:

  • Consulted or is there a foreseeable need to consult with a General Practitioner and/or Specialist for an actual or suspected medical condition?*
  • Please provide the relevant information*
  • Been provided with, and/or are you currently taking any prescription drugs or medication?*
  • Please provide the relevant information*
  • Been admitted to a hospital, clinic or nursing home?*
  • Please provide the relevant information*
  • Undergone regular check-ups (such as, but not limited to: mammograms, colonoscopy, bone density, pap smear, ECG, cholesterol, prostate check-up)?*
  • Please provide the relevant information*
  • Ever suffered from a medical condition or from a known disability or recurrent injury or illness (such as but not limited to: hypertension, diabetes, asthma, recurrent injury)?*
  • Please provide the relevant information*
  • Been refused Private Medical Insurance or Life Assurance cover?*
  • Please provide the relevant information*
  • Been insured or are currently insured under another Private Health Insurance Policy?*
  • Please provide the relevant information*
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  • Been convicted or charged but not yet tried for any offence other than driving offences?*
  • Please provide the relevant information*

  • Dependent 1 - cover and medical history

  • Personal Identification Type*
  • Valid to*
     - -
  • Nationality*
  • Date of Birth*
     - -
  • Gender*
  • Contact Number*
  • Health Scheme Required*
  • Type of cover*
  • Basic Health Scheme Extensions
  • Basic Health Scheme Extensions
  • Hospital Health Scheme Extensions
  • Health Scheme Extensions
  • Family Health Scheme Extensions
  • International Health Scheme Extensions

  • Scheme Extensions: https://www.middlesea.com/insurance-mt/individuals/health-insurance/benefits.jsp

     

  • Within the last five years, have you:

  • Consulted or is there a foreseeable need to consult with a General Practitioner and/or Specialist for an actual or suspected medical condition?*
  • Please provide the relevant information*
  • Been provided with, and/or are you currently taking any prescription drugs or medication?*
  • Please provide the relevant information*
  • Been admitted to a hospital, clinic or nursing home?*
  • Please provide the relevant information*
  • Undergone regular check-ups (such as, but not limited to: mammograms, colonoscopy, bone density, pap smear, ECG, cholesterol, prostate check-up)?*
  • Please provide the relevant information*
  • Ever suffered from a medical condition or from a known disability or recurrent injury or illness (such as but not limited to: hypertension, diabetes, asthma, recurrent injury)?*
  • Please provide the relevant information*
  • Been refused Private Medical Insurance or Life Assurance cover?*
  • Please provide the relevant information*
  • Been insured or are currently insured under another Private Health Insurance Policy?*
  • Please provide the relevant information*
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  • Been convicted or charged but not yet tried for any offence other than driving offences?*
  • Please provide the relevant information*

  • Dependent 2 - cover and medical history

  • Personal Identification Type*
  • Valid to*
     - -
  • Nationality*
  • Date of Birth*
     - -
  • Gender*
  • Please select the unit of measurement to express your height
  • Please select the unit of measurement to express your weight

  • Current Weight

  • Weight 2 years ago
  • Contact Number*
  • Health Scheme Required*
  • Type of cover*
  • Basic Health Scheme Extensions
  • Basic Health Scheme Extensions
  • Hospital Health Scheme Extensions
  • Health Scheme Extensions
  • Family Health Scheme Extensions
  • International Health Scheme Extensions

  • Within the last five years, have you:

  • Consulted or is there a foreseeable need to consult with a General Practitioner and/or Specialist for an actual or suspected medical condition?*
  • Please provide the relevant information*
  • Been provided with, and/or are you currently taking any prescription drugs or medication?*
  • Please provide the relevant information*
  • Been admitted to a hospital, clinic or nursing home?*
  • Please provide the relevant information*
  • Undergone regular check-ups (such as, but not limited to: mammograms, colonoscopy, bone density, pap smear, ECG, cholesterol, prostate check-up)?*
  • Please provide the relevant information*
  • Ever suffered from a medical condition or from a known disability or recurrent injury or illness (such as but not limited to: hypertension, diabetes, asthma, recurrent injury)?*
  • Please provide the relevant information*
  • Been refused Private Medical Insurance or Life Assurance cover?*
  • Please provide the relevant information*
  • Been insured or are currently insured under another Private Health Insurance Policy?*
  • Please provide the relevant information*
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  • Been convicted or charged but not yet tried for any offence other than driving offences?*
  • Please provide the relevant information*

  • Dependent 3 - cover and medical history

  • Personal Identification Type*
  • Valid to*
     - -
  • Nationality*
  • Date of Birth*
     - -
  • Gender*
  • Contact Number*
  • Health Scheme Required*
  • Type of cover*
  • Basic Health Scheme Extensions
  • Basic Health Scheme Extensions
  • Hospital Health Scheme Extensions
  • Health Scheme Extensions
  • Family Health Scheme Extensions
  • International Health Scheme Extensions

  • Within the last five years, have you:

  • Consulted or is there a foreseeable need to consult with a General Practitioner and/or Specialist for an actual or suspected medical condition?*
  • Please provide the relevant information*
  • Been provided with, and/or are you currently taking any prescription drugs or medication?*
  • Please provide the relevant information*
  • Been admitted to a hospital, clinic or nursing home?*
  • Please provide the relevant information*
  • Undergone regular check-ups (such as, but not limited to: mammograms, colonoscopy, bone density, pap smear, ECG, cholesterol, prostate check-up)?*
  • Please provide the relevant information*
  • Ever suffered from a medical condition or from a known disability or recurrent injury or illness (such as but not limited to: hypertension, diabetes, asthma, recurrent injury)?*
  • Please provide the relevant information*
  • Been refused Private Medical Insurance or Life Assurance cover?*
  • Please provide the relevant information*
  • Been insured or are currently insured under another Private Health Insurance Policy?*
  • Please provide the relevant information*
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  • Been convicted or charged but not yet tried for any offence other than driving offences?*
  • Please provide the relevant information*

  • Dependent 4 - cover and medical history

  • Personal Identification Type*
  • Valid to*
     - -
  • Nationality*
  • Date of Birth*
     - -
  • Gender*
  • Contact Number*
  • Health Scheme Required*
  • Type of cover*
  • Basic Health Scheme Extensions
  • Basic Health Scheme Extensions
  • Hospital Health Scheme Extensions
  • Health Scheme Extensions
  • Family Health Scheme Extensions
  • International Health Scheme Extensions

  • Within the last five years, have you:

  • Consulted or is there a foreseeable need to consult with a General Practitioner and/or Specialist for an actual or suspected medical condition?*
  • Please provide the relevant information*
  • Been provided with, and/or are you currently taking any prescription drugs or medication?*
  • Please provide the relevant information*
  • Been admitted to a hospital, clinic or nursing home?*
  • Please provide the relevant information*
  • Undergone regular check-ups (such as, but not limited to: mammograms, colonoscopy, bone density, pap smear, ECG, cholesterol, prostate check-up)?*
  • Please provide the relevant information*
  • Ever suffered from a medical condition or from a known disability or recurrent injury or illness (such as but not limited to: hypertension, diabetes, asthma, recurrent injury)?*
  • Please provide the relevant information*
  • Been refused Private Medical Insurance or Life Assurance cover?*
  • Please provide the relevant information*
  • Been insured or are currently insured under another Private Health Insurance Policy?*
  • Please provide the relevant information*
  • Browse Files
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    Choose a file
    Cancelof
  • Been convicted or charged but not yet tried for any offence other than driving offences?*
  • Please provide the relevant information*

  • Dependent 5 - cover and medical history

  • Personal Identification Type*
  • Valid to*
     - -
  • Nationality*
  • Date of Birth*
     - -
  • Gender*
  • Contact Number*
  • Health Scheme Required*
  • Type of cover*
  • Basic Health Scheme Extensions
  • Basic Health Scheme Extensions
  • Hospital Health Scheme Extensions
  • Health Scheme Extensions
  • Family Health Scheme Extensions
  • International Health Scheme Extensions

  • Within the last five years, have you:

  • Consulted or is there a foreseeable need to consult with a General Practitioner and/or Specialist for an actual or suspected medical condition?*
  • Please provide the relevant information*
  • Been provided with, and/or are you currently taking any prescription drugs or medication?*
  • Please provide the relevant information*
  • Been admitted to a hospital, clinic or nursing home?*
  • Please provide the relevant information*
  • Undergone regular check-ups (such as, but not limited to: mammograms, colonoscopy, bone density, pap smear, ECG, cholesterol, prostate check-up)?*
  • Please provide the relevant information*
  • Ever suffered from a medical condition or from a known disability or recurrent injury or illness (such as but not limited to: hypertension, diabetes, asthma, recurrent injury)?*
  • Please provide the relevant information*
  • Been refused Private Medical Insurance or Life Assurance cover?*
  • Please provide the relevant information*
  • Been insured or are currently insured under another Private Health Insurance Policy?*
  • Please provide the relevant information*
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  • Been convicted or charged but not yet tried for any offence other than driving offences?*
  • Please provide the relevant information*

  • General Information

  • Have you , or any dependent ever been convicted or charged but not yet tried for any offence other than driving offences?
  • Method of payment - This policy is annual, and the full premium is always due, regardless of the payment method you choose.*
  • Direct debit instalments - We only accept instalment payments via direct debit, for all schemes except the Europa Scheme. The first instalment is payable immediately by cash, cheque, card, or bank transfer. We will send you a Direct Debit Mandate form for subsequent instalments.*
  • Requested start date
     - -

  •  

    APPLICABLE LAW

    Unless agreed otherwise in writing, your insurance policies with Mapfre Malta p.l.c (hereinafter referred to as the “Company” or “we”) shall be subject to Maltese Law and to the exclusive jurisdiction of the Maltese courts.

    INSOLVENCY

    In the event that we become insolvent and unable to meet our obligations under this contract, limited compensation may be available to you under the Protection and Compensation Fund Regulations, 2003.

    COMPLAINTS

    We are committed to providing good quality services. We recognise that a client may not be satisfied with the service or product provided, thus the company has in place a complaints procedure. For the sake of clarification, a complaint is broadly defined as being a written expression of dissatisfaction with services that we provide or actions we have taken that require a response.

    HOW TO COMPLAIN

    STEP 1 – CONTACTING THE COMPANY

    The first step is to talk to a member of our personnel or of the intermediary if the Policy was arranged through one. This can be done informally either directly or by telephone.

    Usually the best person to talk to will be the person who dealt with the matter you are concerned about as they will be in the best position to help you promptly and to put things right. If they are not available or you would prefer to approach someone else then address the matter to the manager or senior person responsible. We will seek to resolve the problem immediately. If we cannot do this then we will take a record of the concern and arrange the best way and time for getting back to you. This will normally be within two working days.

    STEP 2 – TAKING THE COMPLAINT FURTHER

    If you are still unhappy, the next step is to put the complaint in writing, addressing it to Complaints Officer, Mapfre Malta p.l.c, Middle Sea House, Floriana FRN 1442 or via e-mail on compofficer@mapfre.mt . Your communication should set out the details, explain what you think went wrong and what you feel would put things right. If you are not happy about writing it, you can always ask one of our staff members to take note of the complaint which you will be then asked to sign. You will be provided with a copy for your own reference. This record will be passed promptly to the Complaints Officer to deal with.

    We will promptly acknowledge your complaint in writing and outline the steps we will take to investigate and resolve it. If we are unable to resolve your complaint within 15 working days, we will inform you of the reason for the delay and provide an estimated timeframe for resolution. Your complaint will be handled confidentially and professionally.

    TAKING YOUR COMPLAINT ELSEWHERE

    If you are still not satisfied with the Complaints Officer’s response, you can always seek advice elsewhere. You may contact:

    Office of the Arbiter for Financial Services
    N/S in Regional Road,
    Msida MSD 1920
    Malta
    Telephone: 8007 2366 or 21249245
    E-mail: complaint.info@financialarbiter.org.mt
    Website: www.financialarbiter.org.mt

    The Office of the Arbiter will expect that you have a final reply to your complaint from us before approaching them. 

  •  

    PERSONAL DATA PROCESSING

    The proposer and/or policyholder is hereby being informed about the data processing that the Data Controller Mapfre Malta p.l.c. will carry out on his/her personal data provided voluntarily, as well as those provided through his/her intermediary, on his/her consultation, insurance application or, if applicable, the contracting of any service or product.

     

    Purposes of processing:

    To manage your insurance application and, if applicable, to manage the contract, preparation of a risk profile for actuarial purposes, fraud prevention and investigation, preparation of a commercial profile for the communication of information and advertising about offers for Mapfre p.l.c.’s products and services, as well as centralized management of your relationship with the Mapfre Group.

     
    Legal basis:

    Execution of the contract, legitimate interest, compliance with legal obligations and consent.

     
    Recipients:

    Data may be disclosed to third parties and/or transferred to third countries in accordance with the terms and conditions stated in the additional data protection Information.

     
    Rights:

    Users may exercise their rights of access, rectification, deletion, restriction, objection, including to automated decision making and portability, as detailed in Additional Information on Data Protection.

     
    Additional Information:

    You may consult the link to Additional Data Protection Information - Mapfre Malta

     

     

     

    If the data provided pertains to physical persons other than the data subject, including health data, the latter guarantees that they have the former’s consent before providing the data, informing them in advance of the data protection terms set out in this document.

     

    The proposer and/or policyholder confirms that they are over 18 years of age. If the data provided by the data subject refers to children under the age of 18, including health data, as the holder of parental authority or guardianship over the minor, you expressly authorize the processing of such data under the terms established in the additional information.

     

    The Proposer and/or Policyholder warrants that the personal data provided is accurate and truthful and undertakes to keep it up to date and to inform Mapfre Malta p.l.c. of any changes made to it.

     

    Mapfre Msv Life p.l.c. and Mapfre Malta p.l.c. have entered into a joint control agreement committing to comply with data protection legislation to process their data jointly under the terms detailed in section “9. Joint control amongst Mapfre Group companies” in the link to Additional Data Protection Information - Mapfre Malta.

     

     

    MARKETING CONSENT

    I want to receive, including in electronic format, personalized sales communications about products and services, discounts, gifts, promotions, and other advantages from the Mapfre Group and other collaborating companies, and therefore I consent to profiling.

    In any case, your consent for processing your data for this purpose is revocable and you may withdraw your consent at any time or exercise any of the rights as described in the link to Additional Data Protection Information - Mapfre Malta. 

  •  

    CONSENT FOR INFORMATION EXCHANGE

    I consent, on my behalf and on behalf of anyone listed in this form, that the Company and its intermediaries or any member of the Group may, for the purpose of preventing, detecting or suppressing fraud or any other reason as compelled by law and for the purpose of administering my insurance proposal and policy and handling and settling claims, exchange some or all of the information including information about my insurance history with Public Authorities, members of the legal or medical profession, insurance undertakings, insurance intermediaries and the Commissioner of Police as may be applicable.

    I also authorize, on my behalf and on behalf of others, insurance companies, intermediaries, medical professionals and health service providers to disclose information about or relevant to my insurance history for these purposes.

    I understand (and have explained to others) that when I inform the Company about an incident that may or may not lead to a claim, the Company may share information related to it with the Malta Insurance Association and/or other insurance companies and intermediaries.

    The Company will ensure that this is carried out confidentially and in accordance with the Professional Secrecy Act, 1994 and as permitted under relevant legislation.

     

    DECLARATION

    I have read or have had read to me the contents of the completed proposal form and agree that all the statements I have made and information I have provided are correct and complete in every respect and will form the basis of the contract between me and Mapfre Malta p.l.c . I undertake to notify Mapfre Malta p.l.c. of any change in the information subsequent to the submitting of this proposal form. I understand that in the event of a finding of incomplete and/or non-disclosure of material information, Mapfre Malta p.l.c. reserves the right to repudiate claims or declare the policy void. I understand and agree that by signing this Declaration I will be bound by the statements and disclosures of material facts herein contained. I confirm that I have received, read and understood the ‘Insurance Product Information Document’, ‘Information for Prospective Policyholders’ and the quotation relevant to the product for which I am applying.

  • Is the device that you are using to complete this claim form touch capable (ex: Mobile phone/tablet)*
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  • Signature of Applicant*
  • Date of Signature
     - -
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  • As dependent 1 is 18 years or over we require their signature as proof of acceptance to the materials provided in this proposal form   
  • Is the device that you are using to complete this claim form touch capable (ex: Mobile phone/tablet)*
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  • Signature of Dependent 1*
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  • Date of Signature
     - -
  • As dependent 2 is 18 years or over we require their signature as proof of acceptance to the materials provided in this proposal form   
  • Is the device that you are using to complete this claim form touch capable (ex: Mobile phone/tablet)*
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  • Signature of Dependent 2*
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  • Date of Signature
     - -
  • As dependent 3 is 18 years or over we require their signature as proof of acceptance to the materials provided in this proposal form   
  • Is the device that you are using to complete this claim form touch capable (ex: Mobile phone/tablet)*
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  • Signature of Dependent 3*
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  • Date of Signature
     - -
  • As dependent 4 is 18 years or over we require their signature as proof of acceptance to the materials provided in this proposal form   
  • Is the device that you are using to complete this claim form touch capable (ex: Mobile phone/tablet)*
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  • Signature of Dependent 4*
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  • Date of Signature
     - -
  • As dependent 5 is 18 years or over we require their signature as proof of acceptance to the materials provided in this proposal form   
  • Is the device that you are using to complete this claim form touch capable (ex: Mobile phone/tablet)*
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  • Signature of Dependent 5*
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  • Date of Signature
     - -

  • Mapfre Malta p.l.c. (C-5553) is authorised by the Malta Financial Services Authority (MFSA) to carry on both long term and general business under the Insurance Business Act, Cap. 403 of the Laws of Malta. Mapfre Malta p.l.c. is regulated by the MFSA.

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