Onderschrijver Name*First name*Sex*MaleFemaleDate of birth*(dd-mm-yyyy)Nationality*Civil status*Bachelor/SingleCohabitantMarriedWidow(er)SeparatedDivorcedProfession*Employer*Street*No.*Box*Postal code*City*E-mail* Telephone number* Risk to insure Location of the risk to insure*Same addressOther addressStreetNo.BoxPostal codeCitySubscriber is*OwnerTenantType of habitation*House (4 sides)House (contiguous)ApartmentDistance to nearest building> 50m< 50mApartment on the ground floorYesNoSurface in m²*Building to insure*YesNoContents to insure*YesNoThatched house*YesNoCombustible materials*< 20%20 - 50%> 50%Contract taken over from another insurer*YesNoName insurerContract numberDue date of current contractNew building*YesNoClaims (last 5 years)Date claimCircumstancesRelevant cover Chosen cover Basic cover (1)*MandatoryTheft*YesNoIndirect claims*YesNoLegal assistance habitation*YesNo Option theft Alarm system*YesNoKnown systemYesNoConnected to a centralYesNoBurglary resistant doorYesNoInhabitation*RegularVacant > 180 nights/year Amounts to cover Contents (estimated value) EUR*Building EUR* Rooms which you should not take into account: The kitchens, bathrooms, rooms smaller than 4m², roof spaces and attics that aren't furnished, uninhabitable annexes (garages excluded) without direct access to the main building. Rooms that you should always take into account: Number of living rooms*(Made up of living, salon and dining room)Number of bedrooms*Number of libraries*Number of offices*Number of porches*Number of sewing or ironing rooms*Number of play rooms*Number of waiting rooms*Number of rooms for liberal profession*Number of garages, even those without direct access to the main building (count the number of parking spots in the garage(s))* Rooms that you should take into account if they are located elsewhere than in the cellar, that is, under the level of the main entrance: Number of laundry rooms*Number of boiler rooms*Number of hobby rooms*Number of storage rooms*TotalCommentsThe system should under no circumstance be used for single-family homes with a lift, nor for buildings with an inside or covered swimming pool or for buildings with more than 13 rooms. Empty rooms, at the time the inventory is made, should be labelled according to their previous or future uses. Not every change to the use of invertorised rooms should be reported, only the addition of more rooms of a kind that was already listed.(1) The basic cover contains among others: fire, explosion, smoke and grime, storm, hail, snow and ice pressure, break of glass, water damages, lightning strike... All data supplied may be processed by Vanbreda Risk & Benefits for the purposes of customer services, risk acceptance, contract management and claims handling. Such data may be communicated to companies with which they have relations, in order to provide the most suitable services. The individuals concerned consent to the given data being processed to the extent necessary for contract acceptance, management and performance by the handlers acting within the context of the contract. This processing is provided for by the Belgian Privacy Protection Law of December 8, 1992. All information will be handled with the utmost discretion.