This form is a request to be included in the mixed medical assistance and reimbursement insurance package marketed by Asistencia Clínica Universitaria de Navarra S.A. de Seguros y Reaseguros (ACUNSA) that includes, on the one hand, the “Insurance Application” itself, which must be completed and signed by the POLICYHOLDER, and on the other hand a declaration or “Health Questionnaire” that must be completed and signed for each person who wants to be included in the insurance or its legal representative. In case of needing more Questionnaires, because it is desired to ensure a greater number of people, there are individual Health Questionnaires that, once completed and signed by the rest of the insured persons must be included in this Insurance Application. The POLICY HOLDER is the person, physical or legal, who together with ACUNSA will sign the contract (insurance policy) and who will be bound in the terms thereof. Acunsa reserves the right to accept or reject, totally or partially, the Request or to propose limitations to the coverage according to the data declared by the applicants. A series of complementary guarantees that each insured can contract as an option. The insurance is annual for calendar years. There are different payment split options.