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MaxMedical Health Insurance of Foreign Nationals

Insurance

Payment

Confirmation

Select insurance

Comprehensive health
insurance of foreign nationals

For long-term stays

Insurance benefits limit up to 600,000 €
Pursuant to the Act on the Stay of Foreign Nationals
Without direct payment by the doctor

from CZK 15 060 per year

Health insurance of necessary
and urgent care

For short-term stays

Insurance benefits limit €60,000
Pursuant to the Act on the Stay of Foreign Nationals
Covers acute treatment

from CZK 510 per month

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Length and scope

The insured

Contact details of the insured

Surname

First name

E-mail

Mobile number

Address of registered residence in the Czech Republic

Street

Street number

Municipality

Postcode

Personal data

Place of birth - municipality

Place of birth - state

Is citizenship different from place of birth?

Yes

nationality

Identity card or passport number

Select gender

Male

Female

Information on health status

I am taking out the insurance for myself.

Yes

Contact details of the person taking out the insurance (policy holder)

Surname

First name

E-mail

Mobile number

Policy holder's contact address

Ulice

Číslo popisné/orientační

Obec

PSČ

Policy holder's personal data

Select gender

Male

Female

Date of birth

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Insurance Conditions

The conclusion of the insurance contract shall be effected by payment of the first premium by the policyholder. By paying the first premium, the policyholder confirms the accuracy of all the information given in the insurance policy and the health questionnaire, if any. This first payment, identified by the variable symbol indicated, must be made solely by the policyholder.

You will receive all necessary documents to the email address indicated, immediately after payment.

Important documents

General Insurance Conditions

Insurance Product-related Information

Pre-contractual Information

Policyholder's declaration

I. Declaration on the processing of personal data
a) I declare that I have been informed of the Information on the processing of personal data by the insurer sufficiently in advance of the conclusion of the insurance contract;
b) I declare that I understand that detailed information on the processing of personal data by the insurer is available on the insurer's internet (website) at www.maximapojistovna.cz/cs/ochrana-osobnich-udaju or with the insurance intermediary who has concluded this insurance policy on behalf of the insurer, or at the insurer's sales outlet;
c) I declare that I consent to the processing of my health data for the purposes of this insurance, or I have the prior consent of the insured (his/her legal representative) to give such consent also in respect of the data about his/her health condition.

The policyholder, who is not also the insured, declares that he/she has all the information about his/her health from the insured (his/her legal representative) in order to complete the health questionnaire truthfully and completely (if applicable) completed). I hereby authorise the insurer, in connection with the exercise of the insurer's rights and performance of the insurer's obligations under the insurance contract, to make enquiries, even after my death (death of the insured), about my (his) health condition with the relevant doctors (medical institutions) and ask them to obtain extracts or copies of medical records or other records of my (his) health condition. I authorize to the doctors (medical facilities) to provide the insurer, at the insurer's request, within the scope of the above authorisation, with the requested information as if they were providing it to the patient.

II. Declaration concerning the insurance contract and the insurance being taken out
1) I declare that I have been informed sufficiently in advance of the conclusion of the insurance contract of all relevant information concerning the insurances being negotiated, in particular:
a) the terms and conditions of insurance governing the insurance being taken out, which are listed in the insurance contract under "Annexes",
b) the other terms and conditions of the insurance and the scope of the insurance, in particular through the documents "Product Information" and "Pre-contractual Information",
2) I declare that I have been informed in detail of all the selected provisions of the insurance policy, in particular the colour-coded parts and the wording of the exclusions, in sufficient time prior to the conclusion of the insurance contract, 89/2012 Coll., the Civil Code, as amended, and I understand and agree to their wording.
3) I confirm that I consider all annexes to be an integral and binding part of the insurance contract.
4) I declare that I have received the Record of Negotiations, including all its annexes, sufficiently in advance of the conclusion of the insurance contract. My insurance requirements and needs have been fully and correctly recorded.
5) I declare that I have read the insurance contract thoroughly, confirm that all the information contained therein is true and complete, and that I understand and agree to the contents of the insurance contract.
6) I declare that I will acquaint the assured, if different from the policyholder, with the contents of the insurance contract, including the stated policy conditions, and with other relevant documents and information communicated to me by the insurer.
The policyholder has chosen the electronic form of all insurance information received by email as appropriate and sufficient. The policyholder has the option to request the insurer to provide the insurance information in paper form at any time.
An insured who is not also the policyholder or a third party for whose benefit the insurance has been taken out may consent to the insurance contract at any time during the term of the contract or only when exercising the right to of the insurance benefit. Consent to the insurance contract shall also mean consent to the contents of the health questionnaire (if drawn up) and to the accuracy of the policyholder's answers to the insured's medical condition.
The insurer warns the policyholder, the insured and the third party that the insurer's questions in the contract, including the health questionnaire (if any), must be answered truthfully and completely. In the event of a breach of these the insurer shall have the right to reduce the insurance benefit or to cancel the entire insurance contract if the insurer would not have concluded the insurance contract if the questions had been answered truthfully and completely.
! The information in this section is a translation of the original Czech text. In case of lack of comprehensibility or inaccuracy of the translation, the original version in Czech takes precedence.

I have read, agree with and acknowledge the above policyholder's declaration.

CONTINUE TO PAYMENT

CZK / 12

Price of insurance: