APolicyHolder


As the policyholder to the Plan, you are the legal representative towards Golden Care of all persons to insure included on this application form. The policyholder may choose not to be insured if cover is required for dependant(s) only.

Title*


Civil Status*

Gender*



Mobile phone*

BCoverage


MENA EveriCover, with a deductible of CHF:
0 50 250 500 1000 2500 5000 10000
MENA EveriCover Plus, with a deductible of CHF:
0 50 250 500 1000 2500 5000 10000
MENA HospiCover, with a deductible of CHF:
0 50 250 500 1000

C Persons to be insured


Fill out the section below, after reading the following specifications:

  • Area 1: Cover without restriction of time in the MENA region and limited to 30 days worldwide, excluding USA and Canada per insurance period.
  • Area 2: Cover without restriction of time worldwide, excluding USA and Canada per insurance period.
The persons to be insured:
  • If you wish to insure more than 4 children, please provide the same information as below on a separate sheet
  • If your child is between 21 and 24 years old and a full-time student, he/she benefits from the 0- to 20- year-old premium rate.
    Please attach proof of student status.
  • Any child up to 20 years old applying alone will be charged the 21- to 24-year-old rate. If several children apply together, the oldest will be charged the adult rate.

Policyholder: Do you wish to be insured?

If yes, select your area of coverage

Do you wish to insure another person?

DPremium


Please select the frequency of your premium: