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Following errors have been found in the form

Joining form - PPHU Orange

Role *

EmployeeEmployee SpouseEmployee Life partnerEmployee Child

Policy_ *

Variant 1Variant 2Variant 3Variant 4

Policy_

Variant 1Variant 2Variant 3Variant 4

Name *

Last Name *

PESEL *

I don't have a PESEL number

Sex *

WomanMan

Date of birth *

-

-

Place of birth *

E-mail *

Telephone no *

Proszę podać numer telefonu używając wyłącznie cyfr, bez spacji i myślników. Numer stacjonarny poprzedź numerem kierunkowym.

Post office town *

Post code *

Town *

Street *

House number *

Apartment number *

Form of employment *

Employment contractCivil law contractContract for specific workOther

Date of employment *

-

-

Date of marriage *

-

-

Life Partner

Life partner – a person with whom you are in a permanent, close relationship and share your life, but you are not married

Life partner name

Life partner last name

Life partner PESEL *

Life Partner does not have a PESEL number

Life partner sex *

WomanMan

Life partner date of birth *

-

-

Life partner place of birth *

Beneficiaries

Beneficiary - the person who will receive the benefit in the event of your death.

Number of Beneficiaries

Beneficiaries 1

Beneficiaries type*

IndividualLegal entity

Percentage of remuneration

Beneficiaries name

Beneficiaries last name

Beneficiaries PESEL*

Beneficiaries does not have a PESEL number

Beneficiaries sex*

WomanMan

Beneficiaries date of birth*

-

-

Beneficiaries place of birth*

Name of the legal entity

REGON*

Beneficiaries 2

Beneficiaries type*

IndividualLegal entity

Percentage of remuneration

Beneficiaries name

Beneficiaries last name

Beneficiaries PESEL*

Beneficiaries does not have a PESEL number

Beneficiaries sex*

WomanMan

Beneficiaries date of birth*

-

-

Beneficiaries place of birth*

Name of the legal entity

REGON*




	*I declare that I have read the information regarding the processing of my personal data contained in the document provided to me Informacja Administratora danych osobowych

	*I consent to receiving information related to my insurance with PZU Życie SA via electronic communication means, including SMS/MMS messages or e-mail, sent to the phone number or e-mail address indicated by me. In the event of any changes to my contact details, I undertake to update them so that I can continue receiving information via electronic communication means.

	*I wish to be covered by insurance with the sum insured and under the terms specified in the agreement that were delivered to me prior to joining the insurance.

	*I consent to PZU Życie SA requesting entities conducting medical activities within the meaning of the provisions on medical activities, which have provided healthcare services to me or my minor children, to provide information about my health condition and the health condition of my minor children as specified in Article 38(2) of the Act on Insurance and Reinsurance Activity, i.e. information on: causes of hospitalization and outpatient treatment, diagnostic tests carried out during such treatment and their results (excluding genetic tests), other healthcare services provided, treatment results, and the results of an autopsy, if performed. Furthermore, I authorize PZU Życie SA to request the above-mentioned entities to provide copies of my medical documentation and the medical documentation of my minor children. I also consent to PZU Życie SA requesting the National Health Fund (NFZ) to provide data on the names and addresses of healthcare providers that have provided healthcare services to me or my minor children in connection with the occurrence of an insured event. The above consents and authorization are intended to enable PZU Życie SA to determine its liability and the amount of benefits in connection with the occurrence of an insured event. Based on these consents and authorization, PZU Życie SA is also entitled to request the above-mentioned information, data, and medical documentation after my death or after the death of my minor children.

	*As of the date of signing the accession declaration, I am not on sick leave, in hospital, hospice, or a long-term care facility, nor am I receiving rehabilitation benefits, and I have not been declared unable to work or unfit for service by a competent authority. This declaration shall apply unless the insurance agreement provides otherwise.

	*WID oświdczenie

	I wish to join the Club under the terms specified in the Club Regulations. I have read and accept its content.

	I consent to receiving marketing information from PZU Pomoc SA and its business partners (a list of partners is available at https://www.pzu.pl/partnerzy_pzu_pomoc) via voice calls (telephone conversations, IVR voice messages).

	To the extent that the processing of your personal data is based on your consent, you have the right to withdraw it. Consent may be withdrawn at any time at a branch office or by sending an e-mail to kontakt@pzu.pl or a letter to PZU, ul. Postępu 18a, 02-676 Warsaw. Withdrawal of consent does not affect the lawfulness of processing carried out on the basis of consent prior to its withdrawal.


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