BSCORDOBA - Adeslas La Eliana

Application Form:

Employee's NIF (Tax identification number) *

Employee's name and surname *

Employee's date of birth *//

Address *

City/Town *

Region *

Phone *

Email *

Policy start date *//

The employee will be covered by the policy. *

Already an Adeslas insured customer? *

Signature *

You may sign with your finger when using a tablet or smartphone or with your mouse if you are using a computer.

In compliance with the provisions of current legislation on Personal Data Protection, we inform you that your personal data will be processed by AHORRAMAS, S.A., in its capacity as data controller, for the purpose of managing the benefits derived from the Flexible Remuneration System. Personal data will be kept for as long as the benefits derived from the Flexible Remuneration System and its legal implications are maintained. The personal data will be transferred to the medical insurance management companies, in particular to SEGURCAIXA ADESLAS S. A. DE SEGUROS Y REASEGUROS with CIF A28011864. You hereby consent to the updating of your personal data, with the exception of your email address, in the existing data processing for the purpose of managing the current employment relationship. You may exercise your rights of access, rectification, cancellation, opposition and other rights in the terms established by applicable legislation, at Ahorramas, Carretera Arganda a Velilla de San Antonio, Km 5, 28891 Velilla de San Antonio (Madrid) or by email to info@ahorramas.com. Further detailed information about our data protection policy is available on request atthe addresses above.

The present document is subject to the employee's subscription to the company's Flexible Remuneration System.

Family members registration:

Beneficiary 1:

Beneficiary's name and surname

NIF

Kinship

Date of birth//

Already an Adeslas insured customer?

Signature

You may sign with your finger when using a tablet or smartphone or with your mouse if you are using a computer.

The present document is subject to the employee's subscription to the company's Flexible Remuneration System.

Beneficiary 2:

Beneficiary's name and surname

NIF

Kinship

Date of birth//

Already an Adeslas insured customer?

Signature

You may sign with your finger when using a tablet or smartphone or with your mouse if you are using a computer.

The present document is subject to the employee's subscription to the company's Flexible Remuneration System.

Beneficiary 3:

Beneficiary's name and surname

NIF

Kinship

Date of birth//

Already an Adeslas insured customer?

Signature

You may sign with your finger when using a tablet or smartphone or with your mouse if you are using a computer.

The present document is subject to the employee's subscription to the company's Flexible Remuneration System.

Beneficiary 4:

Beneficiary's name and surname

NIF

Kinship

Date of birth//

Already an Adeslas insured customer?

Signature

You may sign with your finger when using a tablet or smartphone or with your mouse if you are using a computer.

The present document is subject to the employee's subscription to the company's Flexible Remuneration System.

Beneficiary 5:

Beneficiary's name and surname

NIF

Kinship

Date of birth//

Already an Adeslas insured customer?

Signature

You may sign with your finger when using a tablet or smartphone or with your mouse if you are using a computer.

The present document is subject to the employee's subscription to the company's Flexible Remuneration System.

Adeslas COMPLETE + PLUS DENTAL

34,85 €

monthly/insured party¹

NO WAITING PERIOD

NO COPAYMENT

Adeslas COMPLETE

Application Form:

Family members registration:

Beneficiary 1:

Beneficiary 2:

Beneficiary 3:

Beneficiary 4:

Beneficiary 5:

Adeslas COMPLETE + PLUS DENTAL

34,85 €

monthly/insured party1

NO WAITING PERIOD

NO COPAYMENT

Adeslas COMPLETE

Application Form:

Family members registration:

Beneficiary 1:

Beneficiary 2:

Beneficiary 3:

Beneficiary 4:

Beneficiary 5:

monthly/insured party¹