ExecutiveCover 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

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*

ExecutiveCover 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*

ExecutiveCover 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*