Spouse

Surname

First name

Gender*

M F

Nationality

Date of birth*

Area of
coverage*

1 2

EveriCover quotation

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.

BCoverage

Do you wish to choose the EveriCover Plus option? This option covers dental and maternity. It is available uniquely if you choose a deductible plan of CHF 75 or CHF 400.

Yes No

Your deductible plan for ther EveriCover Plus option is CHF 75 and/or co-insurance of 10%

Choose your deductible plan (in CHF)

75 400 800 1500 4000 8000 15000

C Persons to be insured

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

Area 1: Worldwide limited to 30 days per year in the United States and Canada
Area 2: Worldwide
If your child is between 21 and 24 years ol and full-time student, he/she benefits from the 0-20 years-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?*

Yes No

If yes, select your area of coverage*

1 2

Do you wish to insure another person?

Yes No

Spouse Child Family member

DPremium

Please select the frequency of your premium:*

Yearly Half-yearly (every 6 months) Quarterly (every 3 months) Monthly (every month)

Email address*

Spouse

Gender*

Area of
coverage*

EveriCover quotation

APolicyHolder

Title*

Civil Status*

Gender*

Mobile phone*

BCoverage

C Persons to be insured

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

DPremium

Please select the frequency of your premium:*

Spouse

Gender*

Area of coverage*

EveriCover quotation

APolicyHolder

Title*

Civil Status*

Gender*

Mobile phone*

BCoverage

C Persons to be insured

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

DPremium

Please select the frequency of your premium:*

Area of
coverage*