Form Cerere Viza 420 2-3c-32-ud-8hj2 Nume * Prenume * Email * Telefon * Data nasterii * Varsta Inaltime (cm) * Greutate (kg) * Profesie * Nr Pasaport / Carte de identitate * Tara de provenienta * Cetatenie * Introduceti adresa unde veti locui in Romania Judet / Sector * Oras / Comuna * Strada * Nr. * Bl. Sc. Et. Ap. Copie Pasaport sau Act de Identitate: Incarcati o copie Pasaport / Actul de identitate Click aici pentru a incarca copia de Pasaport/Buletin Choose File Maximum file size: 20MB Acoperiri (in RON) total deces repatriere consultatie spitalizare interventie stomatologie transport perioada Emitere polita de asigurare ASIGURARE OBTINERE VIZA PACHET 31.000 EUR Acoperiri Total cover: 31.000 EUR Covered period: 12 months Death: 1.035 EUR Repatriation in case of death: 14.900 EUR Repatriation in case of medical emergency: 3.900 EUR Emergency cover: Ambulance transport, Medical consult, diagnostic tests, medical emergency treatment: 2.900 EUR Medical emergency treatment: YES Hospitalisation cover in case of emergency: 4.500 EUR Surgery cover in case of emergency: 2.900 EUR Dental cover by accident: 1.035 EUR Preexisting Illness: excluded PACHET 31.000 EUR Pret Asigurare (in RON): Acord GDPR pentru prelucrarea datelor personale * Sunt de acord cu prelucrarea datelor personale in vederea emiterii politei de asigurare Acord emitere polita * Solicit emiterea politei de asigurare Semnatura (desenati pentru a semna) * Clear If you are human, leave this field blank. Trimite Δ
