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Medical Insurance Questionnaire (For Immigration Insurance check our Homepage)

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Your quote request has been successfully submitted.

One of our insurance specialists will contact you shortly to complete the process.

Please note: Based on your answers, we will calculate the cost of your insurance manually to ensure accuracy and the best possible coverage for your needs.

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Main Insured Details

First Name

Last Name

Phone number

Your phone number is required so we can quickly contact you if we need more information or to confirm important details about your insurance request. We respect your privacy and will never share your number without your consent

Main Insured Details

Nationality

At Pitsas Insurance, all clients are treated equally, regardless of their ethnicity or nationality. We ask this question to help us match you with the most suitable insurance advisor. We work with more than 10 qualified advisors from 5 different countries who speak a total of 8 languages. Our goal is to provide you with clear and accurate information in the language you understand best

Sex

City

Date of birth

Add Family members to health insurance

Would you like to add family members to your health plan?

You may include your spouse and any children under 18

Yes

Lifestyle Information

You ( Main Applicant )

Height (cm)

Weight (cm)

Do you smoke?

Yes

Daily consumption (cigarettes per day)

Do you drink alcohol?

Yes

Daily consumption (drinks per week)

Medical history

Do you have or have had any of the following (tick all the apply) Do you or any insured member have or have had any of the following: (tick all that apply)

Other Medical Conditions

Do you have any other medical conditions not listed above?

Yes

Surgeries & Hospitalization

Have you ever had a surgical operation?

Yes

Have you ever been hospitalised without surgery?

Yes

Health Insurance – Choose Coverage

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Medical Insurance Questionnaire (For Immigration Insurance check our Homepage)

You ( Main Applicant )

( Family Member )

High Blood Pressure

High Cholesterol

Diabetes, Thyroid, or other endocrine disorders

Heart disease, irregular heartbeat, chest pain, circulatory system disorders

Stroke

Cancer, polyps, tumors, skin disease

Respiratory diseases (asthma, TB, other)

Liver, stomach, pancreas, or digestive diseases

Kidney, urinary, or reproductive diseases

Neurological diseases (epilepsy, fainting, vertigo, paralysis, etc.)

Mental disorders (depression, anxiety, addiction)

Musculoskeletal disorders (arthritis, rheumatism, spine/joints, muscle disease)

Blood diseases, lymphatic disorders

Infectious diseases (Hepatitis, HIV/AIDS, other chronic contagious disease)

Pending Changes