If You have any questions, please contact the responsible „Gjensidige" employees:

Natalja Lebedeva
natalja.lebedeva@gjensidige.lt
+370 615 600 05

Mindaugas Lipnius
mindaugas.lipnius@gjensidige.lt
+370 698 585 93

Danske Bank health insurance form

Please provide information about yourself

Insurance options: *

I variant: Work experience up to 3 years (the record of 1st December)

Outpatient treatment - € 3000
Inpatient treatment in public hospitals - € 3000
All risks insurance. Alfa - € 240

II variant: Work experience more than 3 years (the record of 1st December)

Outpatient treatment - € 3000
Inpatient treatment in public hospitals - € 3000
All risks insurance. Alfa - € 310

Annex Nr. 4 to the insurance policy GJELT Nr. 2337157

AGREEMENT ON PERSONAL DATA COLLECTION AND PROCESSING

By signing I hereby agree and confirm that:

I agree, that Insured will process my personal data to ADB Gjensidige insurance company for the purpose of Employee health insurance agreement performance and/or administration.

I agree to be insured by ADB Gjensidige insurance company, company number 110057869, headquarters address Žalgirio g. 90, LT-09303 Vilnius, under the terms and conditions of Health insurance rules No. 067 (approved on 2016-03-07 in the Board meeting);

I am familiar with the Health insurance rules No. 067 (approved on 2016-03-07 in the Board meeting), they are clear and understandable to me, I have no comments and I have received a copy of the rules;

I agree that the Insurer or its authorized third parties process my personal data (including cases where this data is provided by the Policyholder), including sensitive personal data about my health condition, medical history, treatment in health care institutions, medical consultations, diagnoses, treatment, details of medical analysis and ailments for the purposes of the insurance contract and for examining of the events that can be recognized as insured events.

I understand and agree that the Insurer makes queries and receives my personal data (including, but not limited to, my full name, personal identification number, information relating to my health condition, medical history, medical consultations, diagnosis, treatment, diseases or ailments, services rendered to me and goods sold to me) by health care institutions, experts, law enforcement, banks, state registers, insurance companies, pharmacies, health service companies, opticians, National Patient Fund, territorial funds of the State Social Insurance Fund Board under the Ministry of Social Security and Labour and other third parties.

I understand and agree that where the Insurer, unnecessarily, provides my personal data, including the above-mentioned sensitive personal data: - to law enforcement authorities, banks, public registries, health care institutions, insurance companies and other third parties in accordance with the needs upon signing the insurance contract, assessing events and/or determining the amounts of insurance benefits; - to persons whose activities are related to the recovery of debts or creation, administration or use of debtor database, so that, if necessary, they can arrange debt management and recovery from the insurer.

I declare that I am aware of my right to object to the processing, obtaining and using my personal data and I am aware that in absence of consent, the contract will not be signed and, if signed – it will be terminated.

- Sveikatos draudimo taisyklės Nr. 067, galioja nuo 2016 03 31

I give my consent for the insurer or its authorized data managers may process my personal details (including the cases where these details are provided by the Policyholder) for marketing purposes as specified in the Law on Personal Data Protection of the Republic of Lithuania (asking opinion, informing about the services provided by the Insurer). This consent shall be valid for the validity period of the certificate of insurance. I also certify that I am aware of my right to object to the Insurer to manage my personal data for direct marketing purposes. I have been informed that this consent is valid until its cancellation in writing or by calling 1626 and that I have the right to disagree with processing of my data for marketing purposes by informing the Insurer thereof in writing or by telephone 1626.