Debtors' Group Life Insurance Application
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ScribdTranslationsDebtors' Group Life Insurance Application
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ScribdTranslationsINDIVIDUAL APPLICATION FOR DEBTORS' GROUP LIFE INSURANCE
City Date of Request
NEW MODIFICATION
Day My Year
I. INFORMATION OF THE POLICYHOLDER
Name or Reason Identification NIT
II. PERSONAL INFORMATION OF THE INSURED
Credit No. Value Capital Type of Document Document Number
CC CE IT
First Surname Second Last Name Names Peso Estatura
Sex Date of Birth Age Current Occupation Marital Status
F M Day My Year
Residence Address E-mail Telephone City
III. COVERAGE AND INSURED VALUE
AMPAROS Insured Value
Death from Any Cause Until the outstanding balance of the debt at the time of the incident
Total and Permanent Disability Until the outstanding balance of the debt at the time of the loss
SINCE IT IS A GROUP DEBTORS LIFE POLICY, THE BENEFICIARY IS CREDIFAMILIA S.A. UP TO THE OUTSTANDING BALANCE OF THE DEBT
DECLARATION OF INSURABILITY (APPLIES TO NEW INSUREDS / INCREASES IN INSURED VALUE)
Declaro que lo anotado en esta solicitud es verídico, que mi estado de salud es normal, que no padezco ni he padecido de enfermedades cardiovasculares, cerebro vasculares,
kidney disorders, congenital diseases, high blood pressure, stroke, cancer, tumors, diabetes, immune disorders, epilepsy, asthma, functional loss
or anatomical, HIV or AIDS. Currently, I do not suffer from chronic diseases, conditions, or addictions that affect my health, and I have not been subjected to or have
scheduled surgical interventions due to the previously mentioned diseases or ailments directly related to them in a casual manner or
consequential. I declare that I am not currently undergoing any medical treatment for any of the previously mentioned diseases or any other different one
not explicitly related. I declare that I am not in the process of disability qualification and that no medical indication has been presented to me that implies a loss
of current work capacity. I do not practice any sports considered high risk or extreme sports, such as but not exclusively, boxing, bullfighting,
alas delta, climbing, mountaineering, motorsport, motorcycling, karting, among others. I also confirm that I have no legal records, all my activities both as
Occupation and profession are legal and I practice them within the legal frameworks. I am aware that any falsehood in this declaration is grounds for nullity of this.
insurance (Article 1058 of the Colombian Commercial Code).
In case of having suffered from any of the diseases mentioned or any other, or having any physical limitations or practicing any extreme or high-risk sports,
please relate the following:
Disease Year of Diagnosis Treatment
RISK RATING (For exclusive use of the Insurer)
I declare that the above is true. That the activity I am engaged in does not pose any risk or hazard to my life. On the other hand, I accept the nullity.
relative to the Insurance Contract, applying Articles 1058 and 1158 of the Commercial Code, if this application incurs in reticence or inherent inaccuracy
to the facts or circumstances described, which, if known by the Global Insurance Company S.A., would have deterred it from entering into the insurance contract or induced
to stipulate more burdensome conditions.
AUTHORIZATIONS
I expressly authorize any doctor, hospital employee, or any person who has treated me or been consulted by me, to provide the company
Mundial de Seguros S.A. all the information it deems necessary. For the purpose of accessing the provision of services by THE INSURER AND/OR THE
INSURANCE INTERMEDIARY, I provide my personal data for all pre-contractual and contractual purposes that encompass insurance activity. PURPOSE OF
PERSONAL DATA PROCESSING: My personal data will be processed by THE INSURER for the following purposes: The processing of my application for affiliation.
As a financial consumer, the process of negotiating contracts with THE INSURER, including the determination of premiums and the selection of risks, the control and the
fraud prevention, comprehensive management of the contracted insurance, preparation of technical-actuarial studies, statistics, surveys, market trend analysis and, in
general, insurance technique studies, sending information related to financial education, customer satisfaction surveys, and commercial insurance offers, the
prevention and control of money laundering and the financing of terrorism, consultation and sending of information to credit risk agencies. The processing may be carried out
directly by the aforementioned companies or by the data processors they consider necessary. That the data may be shared, transmitted, delivered,
transferred or disclosed for the mentioned purposes, to the necessary operators for the fulfillment of rights and obligations derived such as: adjusters, Call
Center, researchers, assistance companies, among others. The answers to the questions they have asked me or will ask me about sensitive personal data are optional.
in accordance with the current legal definition. AUTHORIZATION: Expressly, I AUTHORIZE the processing of personal data including sensitive data and I authorize, if applicable
necessary, the national and international transfer of the same, by the individuals, for the purposes and under the terms that were informed to me in this document, including
the sensitive ones and I authorize, if necessary, the transfer of the same by the people and for the purposes in the terms that were informed to me in this document.
SIGNATURE OF THE INSURED CITY AND DATE FOOTPRINT
FVGD-01-DIS-10/2014