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Translation, Interpreting, Editing/proofreading
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Specializes in:
Law (general)
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Sample translations submitted: 1
Spanish to English: HEALTH AND ACTIVITY QUESTIONNAIRE General field: Medical Detailed field: Law (general)
Source text - Spanish I don´t have it any more
Translation - English HEALTH AND ACTIVITY QUESTIONNAIRE
(TO FILL IN BY THE APPLICANT)
AN INSURANCE ENTITY …………. Nº QUESTIONNAIRE
CAJAGRANADA VIDA , INSURANCE COMPANY AND RE-INSURANCE COMPANY , INC.
PERSONAL DETAILS OF APPLICANT
NAME AND SURNAME ID DATE OF BIRTH SEX PHONE NUMBER
ADDRESS POSTCODE TOWN PROVINCE
ATTENTION: The answers to the questions of this questionnaire have effect on evaluation of the risk by the Insurance Company. The insurance contract that you are asking for is of the highest good faith and CAJAGRANADA VIDA, the Company of Insurance and Re-Insurance Inc. believes in your declarations, but informs you that intentional omissions could invalidate it.
Please, answer to the questions that are made below with yes/no.
1) Are you or have you been on sick leave for more than 15 days during the past 5 years?
2) Have you been examined or treated in hospitals or clinics or had a surgery or received medical treatment in the past 5 years? Were you recommended to do it or are you planning to do it soon?
(Surgeries such as caesarean, appendectomy, tonsillectomy, inguinal hernia and plastic surgeries don’t need to be informed.
3) Are you applying for or do you have any type of recognised invalidity, incapacity or disability.
4) Are you having or have you ever had any illnesses or heart, kidney, liver, neurological, lung, digestive, blood, nervous, psychological, hormonal disease or STD.
5) Have you ever suffered from high blood pressure, diabetes, high cholesterol, hepatitis, depression, anxiety, cancer, heart attack, AIDS, cerebrovascular accident, tumour or spinal disc herniation?
6) Weight kg size cm
7) if you smoke, indicate the amount of cigarettes that you smoke per day.
8) Have you ever had or are you having any pharmacological treatments or are you taking any kind of medication with or without a medical prescription.
9) Have you ever had or were recommended to have an HIV-AIDS test?
10) Are you or have you drunk or used drugs( including cannabis and marijuana)? (in the case of alcohol answer positively, if you consume or have consumed more than 4 units of alcohol/day. One unit of alcohol equals to one glass of wine, one beer, and one shot of liquor(whisky, vodka, gin, rum…)
11) Do you declare that everything you said before is correct and you don’t have anything else to add about your state of health?
12) sports you practise:
Validation
13)Profession:
Validation
14)If you have answered positively to the questions 1, 2 ,3, 4 or 5 or negatively to the question number 11, provide us with more information:………………….
The cause of the disease or injury:……………………………..
Date: approximate duration……months.
Doctors or institutions that attended you:
NAME ADDRESS TOWN PHONE NUMBER
If you have answered positively to the question number 8, indicate:
Name:………………. Amount/day………………………
If you have answered positively to the question number 9, indicate:
Date:………………………… result …………………………
If you have answered positively to the question number 10, indicate:
Name:……………..amount/day……………………………
Applicant allows that all the personal information obtained here will be included in a personal file whose holder and responsible will be CajaGranada Vida the Company of Insurance and Re-Insurance Inc. with the aim of developing, managing and fulfilling the contracted insurance, being able to be the object of treatment by it. Likewise, you specifically authorize the communication of data to the professional doctors for the medical diagnosis and attachment of their conclusions to the mentioned file. Moreover, you will be able to exercise the right of the access, rectification and cancelation, according to the foreseen terms in the Organic law 15/1999 about Protection of information of personal character, if you write to the holder of the file whose address is Calle Reyes Catolicos nº51, 3ª planta, 18001 Granada.
The questions of this questionnaire are obligatory; in the contrary you will make impossible the formalization of contractual relationship.
The signer declares under its responsibility that information provided in this questionnaire is real, promising to communicate in writing to CajaGranada Vida the Company of Insurance and Re-Insurance Inc. any kind of modifications that might happen in them.
Space reserved for the barcode Applicant of the insurance
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Translation education
Bachelor's degree - University of Granada
Experience
Years of experience: 12. Registered at ProZ.com: Jul 2012.
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