Laferla form 2026

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The document is a health insurance proposal form from Laferla Insurance Agency Ltd., acting on behalf of Mapfre Middlesea plc. It collects personal and medical information from the proposer and their dependents to assess eligibility for various health insurance plans. The form includes sections for proposer details, residency, dependent information, required coverage, medical history, data protection clauses, and complaint procedures. It emphasizes the importance of disclosing all relevant medical conditions and personal data consent.

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Click ‘Get Form’ to open it in the editor.
Begin with Section 1 - Proposer Details. Fill in your first name, surname, date of birth, gender, and contact information including mobile and email address.
In Section 2 - Residency, indicate your principal country of residence and whether you or any dependents will be residing away from this country for more than 180 days.
Proceed to Section 3 - Dependents. Enter the details of any dependents, including their names, dates of birth, and relationship to you.
In Section 4 - Cover Required, select the insurance plan that suits your needs by ticking the appropriate box.
Section 5 requires you to disclose medical history. Answer all questions honestly and provide additional details if necessary.
Finally, review Section 6 for data protection information and sign the declaration at the end of the form before submitting.

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Laferla form 2026

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