Online Application

First Name

Last Name

Date of Birth:
Format: Day/Month/Year
Example: 04 JULY 1948

Address

Address Line 2

City

Zip Code

State

Country

Phone (inc country and local code)

I am on Whatsapp

I am on Signal

My Skype username is:

Please make sure all fields are correct and click on NEXT / SAVE to continue.

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Your Email Address

Confirm your Email Address

Please choose a password - min. 8 characters:

Password

Confirm Password

Nationality

Country of Birth

What languages do you and/or your personal helper speak?

If you are a member of a Right To Die (RTD) Organization please let us know which group:

Member of:

Occupation (prior to retirement)

Have you ever been diagnosed with a mental illness?

Have you ever been diagnosed with a mental illness?

YES NO

Diagnosis (max. 300 characters)

Have you ever been diagnosed with a neurological illness

Have you ever been diagnosed with a neurological illness

YES NO

Diagnosis (max. 300 characters)

Please note:

A mental illness will not of itself prevent an application from being accepted by Pegasos. However it remains for Pegasos to determine if a consultation with a Swiss pscychiatritst will be necessary.

Nature of interest in joining Pegasos?

Nature of interest in joining Pegasos?

General interest Support the work of Pegasos Insurance policy for the future To use the service in the coming 12 months

other:

It is important for Pegasos to know who we are talking to so please upload your photo ID here
(Passport).
Max. 5 MB

If you have a living will/ advance directive, please upload the document here.

Please review and then accept the Privacy Policy here:

Please review and then accept the Privacy Policy here:

YES NO

Is there anything else you would like to tell Pegasos at this point?

Please ensure sure you have entered your correct email address and don’t forget to make a note of your password for future use.

When you are ready please click on REGISTER to become a Pegasos Supporter.

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