Membership Form: Portinsurance Care

Policy holder Information

Name *

Address *

Number *

Floor

Postal Code * -

Date of Birth *

Nationality *

Gender * M F

Telephone

Mobile *

Email *

ID / Citizen Card *

NIF *

Marital Status * Single Common-law Marriage Married Separated Divorced Widowed

Number of Children *

Please check your health plan

Multitempo by Job&Talent worker (6,50€) Multitempo by Job&Talent non-worker (9,50€)

Identification of family members to include

Total Monthly Payment Amount __,__ EUR

Payment Frequency

Payment Frequency * Annual Semi-Annual Quarterly Monthly

Note: When the chosen payment frequency is MONTHLY, it is hereby agreed that there will be no advance sending of payment notices, with the dates on which each installment is due and their respective amounts indicated in the Specific Conditions.

Payment Method

Direct Debit Authorization *

Authorization Reference (DDA) to be completed by the creditor

By subscribing to this authorization, you authorize the CREDITOR to send instructions to your BANK to debit your account and, simultaneously, authorize your BANK to debit your account, following the instructions of the CREDITOR. Your rights include the possibility of demanding reimbursement from your BANK of the amount debited, under the terms and conditions agreed with your BANK. Reimbursement must be requested within a period of eight weeks from the date of debit to your account. All fields are mandatory.

Your rights regarding the above-mentioned authorization are explained in a statement that you can obtain from your bank.

Debtor Identification

Name(s) of Debtor(s) *

Account Number / IBAN *

Creditor Identification

Payment Types: * Recurrent Payment

Portinsurance Care Health Plan Declarations

Consent for the Processing of Personal Data

  In accordance with and for the purposes of Law no. 67/98, of October 26 (Data Protection Law), I authorize my personal data to be collected by Portinsurance Care - Health Consulting, Ltd. and RNA - Rede Nacional de Assistência, S.A., which will be processed and stored electronically, intended for compliance with the legal obligations of these entities and for use in contractual relationships between these and other institutions within the scope of the Health Plan, as well as for the promotion of other services and products.
  I also authorize their communication to entities that may be subcontracted to process my data for the same purposes, with the information provided by me subject to strict confidentiality by all entities involved in their processing and access reserved exclusively for what is necessary for their normal activity.
  I am also aware that I may, at any time, access my personal data and/or request its rectification from Portinsurance Care - Health Consulting, Ltd. or RNA - Rede Nacional de Assistência, S.A., in writing or by telephone, and I may also object at any time to the processing of my personal data for marketing purposes.
  I have also been informed that in the case of transmission of my personal data through open networks (Internet), the data may circulate without security conditions, risking being seen and used by unauthorized third parties.

Membership Proposal