International Health Insurance - Valorama

International Health Insurance for expatriates and people with international careers living outside their country of birth. To get a competitive quote, please fill out this form. Then, one of our brokers will contact you as soon as possible and offer you a quote adapted to your profile. If you have a problem (sometimes they Appledo not validate the form), or if you want to share a particularity that could not be reflected here, call us at +33 326 87 82 05.

Name

Name of the person who recommendedValorama ? (if applicable)

Anyone who recommended you to us?

Number of persons to be insured :

nbassures

1 (the principal insured)2 3 4 5

Period to be insured :

From: *

During:

indefinite 3 months 6 months 1 year 2 years

PRIMARY INSURER

Name (payer person) *

Name A1

First name *

First name A1

Date of birth *

Birth A1

Postal address *
(Street, postal code, city, country)

Postmail address

Do you smoke?
(NO if you have not smoked for at least 2 years)

Smoker 1

Yes

Email *

Email A1

Phone number *

Telephone A1

Occupation (exact title of job) *

Profession underwriter

Country of residence for tax purposes

Country of residence for tax purposes Subscriber

Nationality

Nationality of the subscriber

Already with the Social Security in France? If so, which regime?

Affiliation A1

INSURANCE 2 (or spouse to be insured)

SURNAME and first name (Insured 2) :

first name 2

Date of birth:

Date of birth 2

Already with the Social Security in France? If so, which regime?

regime 2

Social security number (if applicable)

numberecu2

ASSURANCE 3

SURNAME and first name (Insured 3) :

first name3

Date of birth:

Date of birth 3

Social security number (if applicable)

numberecu3

ASSURANCE 4

SURNAME and first name (Insured 4) :

namefirstname4

Date of birth:

Date of birth 4

Social security number (if applicable)

numberecu4

ASSURANCE 5

SURNAME and first name (Insured 5) :

nomprenom5

Date of birth:

Date of birth 5

Social security number (if applicable)

numerosecu5

COVERS REQUESTED

Hospitalization only (you will be insured only for hospitalization cases in your insurance policy)

hostile alone

Yes

Hospitalization

hospitalization

Yes

General care (consultations with the general practitioner or specialists, Radiology, X Rays...)

care

Yes

Dentistry and BASIC Ortodonthy (you need classic care, repairs and check-ups...)

dentalbasic

Yes

Dental and Ortodontics MAX (in addition to the traditional care, you need crowns, bridges, implants...)

dental and ortho max

Yes

Optics (you want to be insured for lenses, frames, contact lenses...)

perspective

Yes

Homeopathy

homeopathy

Yes

Alternative medicine (Dietician, Accupuncture, Osteopath, Chiropractor...)

Alternative medicine

Yes

Comment

Free commentary

Attach your passport (or NIC) for fast and accurate processing of your application (optional).

subscriber passport

Attach the current contract in pdf to compare "to covers identical" (optional)

Details or file of the current contract

I have read and accept

I have read and accept the charter on the protection of personal RGPDdata .

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