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Health Insurance

  

Title*

Name & Surname*

ID card number*

Date of birth*

Address*


Phone number*

Mobile number*

Email Address*

Occupation*

Name of Family members to be insured

Name & Surname

Date of Birth

Name & Surname

Date of Birth

Name & Surname

Date of Birth

Name & Surname

Date of Birth

What cover would you like to have?*

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I understand that by completing this form my data will be processed by MIB Group in line with GDPR. I confirm having reviewed MIB’s Privacy Policy  and hereby consent that this data (including if needed sensitive data as defined in article 9 of GDPR) are used for the purpose of providing your insurance services.

 

I also understand that it is my responsibility to secure and hold the necessary consent from any employees, beneficiaries or other third parties directly or indirectly involved in the insurance proposal/arrangements and whose data will be processed by MIB Group and the providers of insurance and ancillary services.