Accident Insurance

Please fill in the form below. Incomplete forms will not be accepted.

Please note that you must fill in one form for each beneficiary. Therefore, if you would like to include a family member you will have to reload the page and fill in a second form with information of the person you wish to include.

E.g.: if you wish to include your son, daughter or spouse, you must fill in one form for each.

Please remember to fill in all fields.

1. Names / Nombres :

2. Last name / Apellidos :

3. Passport number / Rut :

4. Date of birth / Fecha de Nacimiento :

5. Telephone / Teléfono :

6. Address / Dirección Particular :

7. Municipality / Comuna :

8. Isapre / Isapre :

9. Name of beneficiary / Quién es el Afiliado :

10. To identify each new person, please write the name of the Craighouse School staff member, i.e. the name of the holder. If you are the holder, please write your name . / Para identificar a quien corresponde la persona ingresada, favor ingresar nombre del trabajador Craighouse School. Es decir nombre del Titular.
En caso de ser tú el titular, favor ingresar tu nombre.

11. Name of the holder / Nombre del titular :

12. No. of instalments /N° Cuotas :